Final Exam Chat ATI Questions

Question 1

A patient presents with chest discomfort during exercise that is relieved by rest and nitroglycerin. Which coronary artery is most likely involved if the pain is located in the anterior chest and radiates down the left arm? A. Right coronary artery B. Left circumflex artery C. Left anterior descending (LAD) artery D. Pulmonary artery

Answer 1

C. Left anterior descending (LAD) artery

The LAD supplies the anterior wall of the left ventricle — classic location for exertional chest pain.

Question 2

A nurse is assessing a client who reports dizziness when standing and has a history of hypertension. The nurse notes a MAP of 58 mm Hg. What is the priority nursing action? A. Recheck blood pressure in 30 minutes B. Encourage fluid intake C. Notify the provider immediately D. Instruct the client to ambulate

Answer 2

C. Notify the provider immediately

A MAP <60 mm Hg may indicate inadequate organ perfusion.

Question 3

A 74-year-old patient with known CAD reports new confusion and mild dyspnea without chest pain. What is the nurse’s best initial action? A. Ask about recent dietary intake B. Notify the provider immediately C. Administer oxygen D. Obtain a 12-lead ECG

Answer 3

D. Obtain a 12-lead ECG

Older adults may not present with classic symptoms of myocardial ischemia. First assess, then intervene.

Question 4

The nurse auscultates a murmur over the 5th ICS, left midclavicular line. Which valve is likely affected? A. Tricuspid B. Pulmonic C. Aortic D. Mitral

Answer 4

D. Mitral

This is the mitral (apical/PMI) landmark — commonly assessed for regurgitation or stenosis.

Question 5

During assessment, a patient has bounding pedal pulses rated at 4+. What could this indicate? A. Hypovolemia B. Normal finding C. Fluid overload or increased CO D. Decreased perfusion to the extremities

Answer 5

C. Fluid overload or increased CO

Bounding pulses may reflect high stroke volume or pressure.

Question 6

A patient’s lab values reveal elevated troponin I and T, but no ST elevation is present on ECG. Which condition is most likely? A. Unstable angina B. STEMI C. NSTEMI D. Stable angina

Answer 6

C. NSTEMI

This is myocardial infarction without ST elevation but with evidence of damage (elevated troponins).

Question 7

A client is undergoing a cardiac stress test. What finding would require the nurse to stop the test immediately? A. HR increase from 75 to 95 B. Mild fatigue C. ST segment depression on ECG D. Reported muscle cramps in the legs

Answer 7

C. ST segment depression on ECG

Indicates myocardial ischemia. Test should be stopped and evaluated.

Question 8

A patient recovering from an MI has a MAP of 55 mm Hg, cool extremities, and altered mental status. Which hemodynamic issue does this most likely reflect? A. High preload B. Increased contractility C. Low cardiac output D. Elevated afterload

Answer 8

C. Low cardiac output

Signs indicate poor perfusion, likely due to impaired ventricular function post-MI.

Question 9

A nurse is educating a patient on how the autonomic nervous system affects the heart. Which statement indicates understanding? A. “The sympathetic system slows my heart rate.” B. “The parasympathetic system raises my blood pressure.” C. “The vagus nerve is part of the sympathetic response.” D. “The sympathetic system increases heart rate and contractility.”

Answer 9

D. “The sympathetic system increases heart rate and contractility.”

Correct explanation of SNS influence on cardiac function.

Question 10

A patient with chronic hypertension is showing signs of left ventricular hypertrophy on echocardiography. Which concept explains this adaptation? A. Increased preload B. Decreased afterload C. Increased afterload D. Decreased contractility

Answer 10

C. Increased afterload

The left ventricle thickens to overcome increased systemic vascular resistance.
more
Preload and Afterload – CARDS RX (explained)
Afterload is the amount of resistance the heart has to overcome to pump blood out into the circulatory system. Essentially, it’s the pressure the ventricles need to generate to open the semilunar valves (aortic and pulmonary) and eject blood during systole. It’s influenced by the resistance in the arteries and the stiffness of the arterial walls.

Question 11

A nurse is reviewing the chart of a client with consistently elevated BP readings over the past month. Which entry would support a diagnosis of primary hypertension? A. History of polycystic kidney disease B. Elevated creatinine and protein in urine C. Sedentary lifestyle and BMI of 34 D. BP elevation only during office visits

Answer 11

C. Sedentary lifestyle and BMI of 34

Primary HTN is linked to modifiable risk factors like obesity and inactivity.

Question 12

A 55-year-old client has a BP reading of 148/94 mmHg. What is the nurse’s next best action? A. Diagnose the client with hypertension B. Reassess BP on a different day C. Administer antihypertensive medication D. Instruct the client to restrict fluids

Answer 12

B. Reassess BP on a different day

Diagnosis requires two+ elevated readings on separate visits.

Question 13

A client presents to the ED with BP 210/152 mmHg, headache, blurred vision, and dyspnea. Which action should the nurse take first? A. Administer a stat antihypertensive IV B. Place the client on seizure precautions C. Call the Rapid Response Team D. Reassess BP manually in both arms

Answer 13

A. Administer a stat antihypertensive IV

This is a hypertensive crisis — immediate BP reduction is required to prevent organ damage.

Question 14

A nurse is counseling a client newly diagnosed with HTN. Which statement by the client indicates a need for further teaching? A. “I should reduce my sodium intake.” B. “I’ll stop my medication once my BP is normal.” C. “I’ll start walking 30 minutes, 3 times a week.” D. “I’ll read food labels for sodium content.”

Answer 14

B. “I’ll stop my medication once my BP is normal.”

HTN requires long-term treatment — stopping meds abruptly can lead to rebound HTN.

Question 15

A nurse is educating a client with newly prescribed lisinopril. Which symptom should the client report to the provider? A. Mild fatigue B. Dry cough C. Increased appetite D. Slight dizziness when standing

Answer 15

B. Dry cough

ACE inhibitors like lisinopril commonly cause a dry cough — may require a med change.

Question 16

A client with secondary hypertension has a low GFR and elevated BUN/Creatinine. Which underlying cause is most likely? A. Obesity B. Vaping C. Kidney disease D. Stress

Answer 16

C. Kidney disease

Kidney disease is a common cause of secondary HTN and affects renal filtration markers.

Question 17

The nurse is assessing a client who reports fatigue and facial flushing. BP is 162/98. What is the nurse’s priority assessment? A. Check for dependent edema B. Ask about recent salt intake C. Assess for medication adherence D. Review cardiovascular and renal history

Answer 17

D. Review cardiovascular and renal history

HTN affects target organs — assess for end-organ damage.

Question 18

A nurse is discussing the DASH diet with a client. Which meal option indicates correct understanding of the diet? A. Ham sandwich with cheese and chips B. Grilled salmon, brown rice, and steamed broccoli C. Fried chicken with mashed potatoes and gravy D. Bacon, eggs, and white toast with butter

Answer 18

B. Grilled salmon, brown rice, and steamed broccoli

The DASH diet emphasizes lean protein, whole grains, and low sodium.

Question 19

A nurse is planning care for a hypertensive client with poor medication adherence. Which intervention best addresses this issue? A. Ask if they have a pill organizer B. Refer to a dietitian C. Educate on measuring BP at home D. Assess financial ability to afford medications

Answer 19

D. Assess financial ability to afford medications

Cost is a common barrier to adherence and must be addressed directly.

Question 20

A client taking antihypertensive medication reports dizziness upon standing. What is the nurse’s best response? A. “You should stop the medication immediately.” B. “That’s normal and nothing to worry about.” C. “Change positions slowly and call if it gets worse.” D. “This likely means the medication isn’t working.”

Answer 20

C. “Change positions slowly and call if it gets worse.”

Orthostatic hypotension is a common side effect — safety education is key.

Question 21

A client with a history of smoking and diabetes reports calf pain while walking that is relieved by rest. What is the nurse’s priority action? A. Assess dorsalis pedis and posterior tibial pulses B. Apply compression stockings to improve circulation C. Elevate the legs above heart level D. Instruct the client to avoid all physical activity

Answer 21

A. Assess dorsalis pedis and posterior tibial pulses

Intermittent claudication is a classic symptom of PAD; peripheral pulse assessment helps confirm impaired perfusion.

Question 22

A nurse notes thin, shiny skin and a loss of hair on a client’s lower legs. Which condition should the nurse suspect? A. Venous insufficiency B. Arterial occlusion C. Deep vein thrombosis D. Cellulitis

Answer 22

B. Arterial occlusion

Skin changes like shiny, hairless legs suggest poor arterial circulation due to PAD.

Question 23

A client has an Ankle-Brachial Index (ABI) of 0.76. What does this result indicate? A. Normal arterial blood flow B. Mild venous insufficiency C. Moderate peripheral arterial disease D. Severe deep vein thrombosis

Answer 23

C. Moderate peripheral arterial disease

An ABI <0.90 confirms PAD; 0.76 suggests moderate disease.

Question 24

A nurse is developing a plan of care for a client with PAD. Which intervention is inappropriate? A. Encourage walking to the point of pain B. Elevate legs above the level of the heart C. Recommend smoking cessation D. Apply warmth to promote vasodilation

Answer 24

B. Elevate legs above the level of the heart

Elevating legs above the heart reduces arterial perfusion in PAD — legs should be kept in a dependent position.

Question 25

A client with PAD complains of numbness and burning in the feet. What is the nurse’s best interpretation? A. Symptoms of fluid overload B. Expected signs of neuropathy in PAD C. Normal aging signs D. Complication of venous insufficiency

Answer 25

B. Expected signs of neuropathy in PAD ## Footnote Paresthesia and burning pain may occur due to chronic ischemia, especially in diabetics.

Question 26

A nurse is teaching a client with PAD about foot care. Which instruction should be included? A. Use heating pads directly on the feet for warmth B. Walk barefoot at home to promote circulation C. Inspect feet daily for sores or color changes D. Soak feet in hot water daily to improve tissue perfusion

Answer 26

C. Inspect feet daily for sores or color changes ## Footnote Clients with PAD are at risk for ulcers and gangrene — daily inspection is critical.

Question 27

Which modification would be most effective in reducing PAD progression? A. Increasing dietary calcium B. Taking warm baths twice a day C. Discontinuing all physical activity D. Quitting tobacco use

Answer 27

D. Quitting tobacco use ## Footnote Tobacco use is the most significant modifiable risk factor for PAD — cessation is critical.

Question 28

A client with a recent diagnosis of PAD asks why they need aspirin daily. What is the nurse’s best response? A. “It lowers your blood pressure.” B. “It prevents ulcers from forming.” C. “It helps prevent blood clots in narrowed arteries.” D. “It improves oxygen delivery to muscles.”

Answer 28

C. “It helps prevent blood clots in narrowed arteries.” ## Footnote Aspirin is an antiplatelet agent used to reduce clot formation in narrowed vessels.

Question 29

Which physical assessment finding is most concerning in a client with PAD? A. Ankle swelling in the evening B. Skin that is red when the leg is dependent C. Cool, pale skin with absent pedal pulses D. Brown discoloration over the medial ankle

Answer 29

C. Cool, pale skin with absent pedal pulses ## Footnote This may indicate critical limb ischemia — requires urgent evaluation.

Question 30

A client with a history of arteriosclerosis is being educated on preventing complications. Which goal is most important? A. Increase calcium intake B. Maintain systolic BP under 160 mmHg C. Reduce LDL cholesterol levels D. Avoid vitamin supplements

Answer 30

C. Reduce LDL cholesterol levels ## Footnote High LDL contributes to plaque buildup — reducing it lowers the risk of MI, stroke, and PAD.

Question 31

Which of the following are normal aging process(es) that elderly patients will see? Select all that apply. a. Myocardial contractility decreases. b. Fatty tissue is redistributed. c. Hormone production increases. d. Muscle mass increases. e. Thoracic expansion decreases.

Answer 31

a, b, e ## Footnote Hormone production and muscle mass typically decrease with aging.

Question 32

Which statement by an older adult indicates that further teaching or intervention is needed? a. 'I drink prune juice every day and that keeps me from having a bowel movement regularly.' b. 'I just joined the gym near my house. I plan to go there three times a week.' c. 'I eat fiber every day including whole grain, raw vegetables, and fruits.' d. 'I will stop drinking fluids after 5pm so I don’t need to go to the bathroom at night.'

Answer 32

d ## Footnote This may lead to dehydration and constipation.

Question 33

Which assessment finding may be present in a 79-year-old client with delirium? Select all that apply. A. Psychosis B. Bacteria in urine C. Temperature 101.9°F D. Oxygen saturation 89% E. Has been present for 6 months.

Answer 33

A, B, C, D ## Footnote Delirium is characterized by acute onset and fluctuating symptoms.

Question 34

Which question will the nurse ask when assessing a client who smells of alcohol? Select all that apply. A. 'Do you drink like this often?' B. 'Why were you out drinking tonight?' C. 'Are you telling the truth about drinking?' D. 'Do people annoy you by criticizing your drinking?' E. 'Have you ever tried to cut down on your drinking?' F. 'Have you ever had a drink in the morning to settle your nerves?'

Answer 34

E, D, F ## Footnote These questions are part of the CAGE questionnaire for alcohol use assessment.

Question 35

What is the most appropriate response by the nurse to an 82-year-old client who feels old and useless?

Answer 35

c. 'Let’s talk about your interests; older adults are very capable of learning new things.' ## Footnote This response reinforces the older adult's capacity for learning and self-worth.

Question 36

What is the nurse’s priority action for an older adult with a high Morse Fall Risk score of 60?

Answer 36

b. Place a 'high fall risk' sign at the bedside and implement fall precautions. ## Footnote A Morse score >51 indicates high risk for falls.

Question 37

What is the most likely pharmacologic effect of increased fat stores in older adults when prescribed a fat-soluble medication?

Answer 37

c. Drug stored in fat tissue, leading to prolonged drug action ## Footnote Increased body fat results in greater distribution and storage of fat-soluble drugs.

Question 38

What is the nurse's priority teaching for an older adult who reports trouble tasting food and often skips meals due to fatigue?

Answer 38

c. 'Try small, frequent, nutrient-dense meals and consider softer foods.' ## Footnote This addresses barriers such as fatigue, taste changes, and dentures.

Question 39

Which action requires immediate correction when administering medications to an older adult?

Answer 39

c. Nurse crushes an extended-release tablet due to patient’s swallowing issues. ## Footnote Crushing extended-release medications alters absorption and can lead to toxicity.

Question 40

What is the best initial action for a nurse when an older adult suddenly becomes confused and begins hallucinating?

Answer 40

b. Use a calm voice and reorient the patient frequently. ## Footnote Frequent reorientation is part of initial non-pharmacological interventions for delirium.

Question 41

What is included in the Braden Scale assessment? Select all that apply.

Answer 41

a. Moisture, b. Mobility, c. Nutrition, e. Sensory perception, g. Activity, h. Friction and shear ## Footnote The Braden Scale assesses risk for pressure ulcers.

Question 42

Which findings in an 85-year-old client using the SPICES framework would require further nursing intervention? Select all that apply.

Answer 42

b. Skin redness noted over the sacral area, c. Disoriented to time and place, e. Declining to eat meals and reports poor appetite ## Footnote These findings indicate potential issues with skin integrity, cognition, and nutrition.

Question 43

What is the primary reason for applying a cold pack to a patient with multiple contusions on the lower extremities?

Answer 43

b. To reduce bleeding and swelling ## Footnote Cold therapy causes vasoconstriction, minimizing bleeding and inflammation.

Question 44

A client presents with chest pain that began at rest and is not relieved by nitroglycerin. The ECG shows no ST elevation, and troponin levels are normal. Which condition is most likely? A. Stable angina B. NSTEMI C. STEMI D. Unstable angina

Answer 44

D. Unstable angina ## Footnote Unstable angina is unpredictable, not relieved by rest or nitro, and has normal troponins and no ST elevation.

Question 45

A nurse is assessing a client with chest pain that occurs predictably with exertion and resolves with rest. What is the nurse’s next best action? A. Call a code B. Administer oxygen and prepare for PCI C. Administer nitroglycerin and monitor pain D. Begin CPR immediately

Answer 45

C. Administer nitroglycerin and monitor pain ## Footnote This is likely stable angina, and nitroglycerin is appropriate. CPR and emergency interventions aren’t indicated unless it worsens.

Question 46

Which client report is most concerning and suggests progression from stable angina to acute coronary syndrome? A. “The pain starts when I mow the lawn.” B. “I’ve had the same chest pain for 10 years.” C. “The pain feels the same every time.” D. “The pain came on suddenly at rest and feels different than usual.”

Answer 46

D. “The pain came on suddenly at rest and feels different than usual.” ## Footnote A change in pattern or onset at rest suggests unstable angina or evolving MI.

Question 47

Which finding would confirm a STEMI in a client with chest pain? A. ST depression and low potassium B. Normal ECG and elevated potassium C. ST elevation and elevated troponin D. ST elevation with normal troponin

Answer 47

C. ST elevation and elevated troponin ## Footnote A STEMI is diagnosed by ST elevation on ECG and elevated cardiac enzymes (troponins).

Question 48

A nurse is teaching about NSTEMI. Which statement by the client shows correct understanding? A. “It’s not a heart attack because there’s no ST elevation.” B. “Since there’s no ST elevation, it’s not serious.” C. “My troponin levels will still be elevated.” D. “This only happens if my heart valves are damaged.”

Answer 48

C. “My troponin levels will still be elevated.” ## Footnote NSTEMIs show no ST elevation, but troponins are elevated due to myocardial damage.

Question 49

The nurse is caring for a client with chest pain, diaphoresis, and ST elevation in leads II, III, and aVF. What is the priority action? A. Administer morphine and monitor B. Prepare for emergency PCI C. Monitor troponins every 6 hours D. Document findings and reassess in 1 hour

Answer 49

B. Prepare for emergency PCI ## Footnote STEMI is a medical emergency. Reperfusion therapy (PCI or thrombolytics) must be initiated immediately.

Question 50

A client reports chest discomfort that improves with nitroglycerin and occurs with activity. Their ECG and troponins are normal. What should the nurse suspect? A. NSTEMI B. Unstable angina C. Stable angina D. STEMI

Answer 50

C. Stable angina ## Footnote Stable angina is predictable, relieved by nitro, and does not cause ECG or troponin abnormalities.

Question 51

Which diagnostic result is most important to differentiate unstable angina from NSTEMI? A. Blood pressure B. ECG changes C. Troponin levels D. Chest X-ray

Answer 51

C. Troponin levels ## Footnote Elevated troponins indicate myocardial injury = NSTEMI. Normal troponins = unstable angina.

Question 52

A client with chest pain receives a 12-lead ECG. The nurse notes no ST elevation, but troponin levels are elevated. Which term best describes the condition? A. STEMI B. Stable angina C. Unstable angina D. NSTEMI

Answer 52

D. NSTEMI ## Footnote Troponin elevation without ST elevation = NSTEMI.

Question 53

A client with a history of stable angina calls the clinic and reports more frequent pain, now occurring at rest. What is the nurse’s best response? A. “Take nitroglycerin and rest; call if it continues.” B. “Go to the ER immediately.” C. “Increase your activity gradually.” D. “Make an appointment within the next week.”

Answer 53

B. “Go to the ER immediately.” ## Footnote New or worsening chest pain at rest suggests unstable angina or MI and requires emergency care.

Question 54

A nurse is reviewing factors contributing to heart failure. Which condition most directly reduces myocardial contractility, leading to systolic dysfunction? A. Aortic stenosis B. Myocardial infarction C. Pulmonary embolism D. Atrial fibrillation

Answer 54

B. Myocardial infarction ## Footnote An MI causes myocardial tissue death, reducing the heart’s ability to contract—a key feature of systolic heart failure.

Question 55

A patient with long-standing uncontrolled hypertension develops heart failure. Which mechanism most likely contributes to this condition? A. Increased contractility B. Decreased heart rate C. Increased afterload D. Decreased preload

Answer 55

C. Increased afterload ## Footnote Uncontrolled hypertension raises afterload, making it harder for the heart to eject blood, leading to ventricular hypertrophy and failure.

Question 56

The nurse explains that diastolic heart failure results primarily from: A. Decreased stroke volume due to reduced ejection fraction B. Stiff ventricles preventing adequate filling C. Overstretched ventricular walls from fluid overload D. Impaired conduction through the AV node

Answer 56

B. Stiff ventricles preventing adequate filling ## Footnote Diastolic HF is caused by impaired ventricular relaxation and filling, even if ejection fraction is preserved.

Question 57

Which factor directly impacts preload in the cardiac cycle? A. Aortic valve stenosis B. Fluid volume status C. Peripheral vascular resistance D. Pulmonary artery pressure

Answer 57

B. Fluid volume status ## Footnote Preload is primarily influenced by venous return and blood volume.

Question 58

A client with a history of MI is at increased risk for heart failure because: A. MIs impair ventricular filling by damaging valves B. MIs reduce cardiac output by impairing contractility C. MIs increase preload through blood pooling D. MIs raise systemic vascular resistance

Answer 58

B. MIs reduce cardiac output by impairing contractility ## Footnote Heart failure post-MI is typically due to loss of contractile function from infarcted myocardium.

Question 59

The nurse is monitoring a patient with heart failure. Which finding indicates impaired cardiac output? A. Bounding peripheral pulses B. Cool extremities and delayed capillary refill C. Bradycardia and hypertension D. Loud S1 and increased urine output

Answer 59

B. Cool extremities and delayed capillary refill ## Footnote These signs reflect poor perfusion due to low cardiac output.

Question 60

An older adult hospitalized for heart failure asks, “Why did I develop this now?” The nurse explains: A. “It’s likely due to long-standing liver disease.” B. “Your age and possible previous heart damage may have contributed.” C. “It’s usually caused by an infection.” D. “You probably inherited this from your parents.”

Answer 60

B. “Your age and possible previous heart damage may have contributed.” ## Footnote HF is more common in older adults due to cumulative cardiovascular stress and events like MI.

Question 61

The nurse is teaching a new graduate about right-sided heart failure. Which cause is most closely associated? A. Left-sided heart failure B. Uncontrolled diabetes C. Coronary artery disease D. Mitral valve regurgitation

Answer 61

A. Left-sided heart failure ## Footnote Right-sided HF often develops as a consequence of chronic left-sided HF, due to backup into the pulmonary circulation.

Question 62

Which clinical finding best reflects the compensatory response to low cardiac output in heart failure? A. Decreased respiratory rate B. Increased urine output C. Tachycardia D. Hypotension

Answer 62

C. Tachycardia ## Footnote The body compensates for low cardiac output by activating the sympathetic nervous system, leading to increased heart rate.

Question 63

In a patient with heart failure, which of the following would indicate ineffective tissue perfusion? A. Warm, flushed skin B. Increased energy level C. Confusion and restlessness D. Polyuria

Answer 63

C. Confusion and restlessness ## Footnote These are early signs of decreased cerebral perfusion, a result of low cardiac output in HF.

Question 64

A nurse is reviewing a patient's medical history and notes a diagnosis of left-sided heart failure. Which of the following symptoms are most commonly associated with this condition? (Select all that apply) A. Shortness of breath B. Hepatomegaly C. Crackles in the lungs D. Pink, frothy sputum E. Jugular vein distension

Answer 64

A. Shortness of breath, C. Crackles in the lungs, D. Pink, frothy sputum ## Footnote Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, crackles in the lungs, and pink frothy sputum due to pulmonary edema.

Question 65

Which of the following can contribute to the development of systolic left-sided heart failure? (Select all that apply) A. Myocardial infarction (MI) B. Chronic obstructive pulmonary disease (COPD) C. Uncontrolled hypertension D. Valvular disease E. Aortic stenosis

Answer 65

A. Myocardial infarction (MI), C. Uncontrolled hypertension, D. Valvular disease ## Footnote Systolic left-sided heart failure occurs when the heart cannot pump effectively, which can be caused by MI, uncontrolled hypertension, and valvular disease.

Question 66

A patient with left-sided heart failure has a decreased ejection fraction of 38%. What is the risk associated with this finding? A. Increased risk of stroke B. High risk for cardiac death C. Increased risk for pulmonary embolism D. Decreased risk of myocardial infarction

Answer 66

B. High risk for cardiac death ## Footnote A decreased ejection fraction (<40%) in systolic heart failure indicates a high risk of cardiac death, requiring close monitoring.

Question 67

Which of the following are signs of right-sided heart failure? (Select all that apply) A. Jugular vein distension (JVD) B. Crackles in the lungs C. Peripheral edema D. Hepatomegaly E. Pink, frothy sputum

Answer 67

A. Jugular vein distension (JVD), C. Peripheral edema, D. Hepatomegaly ## Footnote Right-sided heart failure causes blood to back up into the venous circulation, resulting in JVD, peripheral edema, and hepatomegaly.

Question 68

Which of the following conditions can lead to right-sided heart failure? (Select all that apply) A. Right-sided myocardial infarction B. Pulmonary hypertension C. Chronic obstructive pulmonary disease (COPD) D. Uncontrolled hypertension E. Left-sided heart failure

Answer 68

A. Right-sided myocardial infarction, B. Pulmonary hypertension, C. Chronic obstructive pulmonary disease (COPD), E. Left-sided heart failure ## Footnote Right-sided heart failure is often caused by right-sided MI, pulmonary hypertension, COPD, and left-sided heart failure.

Question 69

A nurse is caring for a patient with diastolic left-sided heart failure. Which of the following findings would be expected in this patient? A. Decreased ejection fraction B. Normal ejection fraction C. Left ventricular hypertrophy D. Pulmonary edema due to impaired relaxation

Answer 69

B. Normal ejection fraction, C. Left ventricular hypertrophy ## Footnote Diastolic heart failure is characterized by normal ejection fraction but impaired relaxation and filling of the left ventricle, often due to left ventricular hypertrophy.

Question 70

In systolic left-sided heart failure, the hallmark finding is a decreased ejection fraction (EF). What is the normal range for EF in healthy individuals? A. 30–40% B. 50–70% C. 60–80% D. 70–90%

Answer 70

B. 50–70% ## Footnote A normal ejection fraction is 50–70%. EF below 40% suggests systolic heart failure.

Question 71

A patient with right-sided heart failure is being assessed for signs of fluid congestion. Which of the following symptoms would the nurse expect to find in this patient? A. Pulmonary edema B. Ascites C. Hepatomegaly D. Crackles in the lungs E. Pitting edema in lower extremities

Answer 71

B. Ascites, C. Hepatomegaly, E. Pitting edema in lower extremities ## Footnote Right-sided heart failure causes fluid buildup in the venous circulation, leading to ascites, hepatomegaly, and pitting edema in the lower extremities.

Question 72

A nurse is educating a patient about diastolic left-sided heart failure. Which of the following conditions are likely causes of this type of heart failure? (Select all that apply) A. Left ventricular hypertrophy B. Myocardial infarction C. Valvular disease D. Coronary artery disease E. Increased ejection fraction

Answer 72

A. Left ventricular hypertrophy, B. Myocardial infarction, C. Valvular disease ## Footnote Diastolic heart failure is often caused by left ventricular hypertrophy, MI, and valvular disease.

Question 73

Which of the following statements is true regarding left-sided heart failure? A. It causes blood to back up into the systemic circulation. B. It often results in pulmonary congestion and edema. C. The ejection fraction is usually elevated in systolic heart failure. D. It is most commonly caused by right-sided heart failure.

Answer 73

B. It often results in pulmonary congestion and edema. ## Footnote Left-sided heart failure results in pulmonary congestion and edema, as blood backs up into the left atrium and pulmonary veins.

Question 74

Which of the following is a common cause of high-output heart failure? (Select all that apply) A. Septicemia B. Severe anemia C. Myocardial infarction D. Hyperthyroidism E. Hypertension

Answer 74

A. Septicemia, B. Severe anemia, D. Hyperthyroidism ## Footnote High-output heart failure is typically caused by conditions that increase the demand on the heart, such as septicemia, severe anemia, and hyperthyroidism.

Question 75

In high-output heart failure, cardiac output is typically normal or elevated, yet tissues remain underperfused. Which of the following could explain this phenomenon? A. Increased peripheral resistance B. Decreased tissue oxygenation despite increased cardiac output C. Impaired ability of the heart to pump effectively D. Blockage in the coronary arteries

Answer 75

B. Decreased tissue oxygenation despite increased cardiac output ## Footnote In high-output heart failure, tissues are underperfused despite normal or elevated cardiac output, often due to a mismatch between oxygen delivery and demand.

Question 76

What is a characteristic of high-output heart failure?

Answer 76

It is typically acute and potentially reversible if treated early ## Footnote High-output heart failure is usually acute, caused by conditions like septicemia or hyperthyroidism, and it can be reversible with proper treatment.

Question 77

What clinical finding is likely observed in a patient with high-output heart failure?

Answer 77

Warm skin with bounding pulses ## Footnote In high-output heart failure, the heart pumps adequately or more than enough, but tissues are still underperfused.

Question 78

Which intervention is appropriate for a patient with high-output heart failure caused by severe anemia?

Answer 78

Administering iron supplementation or blood transfusion ## Footnote Severe anemia increases the demand for oxygen, and treating the underlying cause is essential.

Question 79

Which statement is true regarding high-output heart failure?

Answer 79

It occurs when there is an increased demand for oxygen that exceeds the heart’s ability to meet it, despite normal or elevated output ## Footnote Increased oxygen demand due to conditions like severe anemia or septicemia leads to underperfusion of tissues.

Question 80

What should a nurse emphasize to a patient with hyperthyroidism regarding high-output heart failure?

Answer 80

Ensure regular monitoring of heart rate and blood pressure ## Footnote Hyperthyroidism can lead to increased metabolism and oxygen demand, thus increasing heart failure risk.

Question 81

What is the priority intervention for a patient with high-output heart failure secondary to septicemia?

Answer 81

Administer IV fluids and vasopressors to maintain blood pressure ## Footnote IV fluids and vasopressors stabilize blood pressure and improve tissue perfusion in septicemia.

Question 82

Which of the following is a reversible cause of high-output heart failure?

Answer 82

Hyperthyroidism ## Footnote Hyperthyroidism increases metabolic demand on the heart and can be treated to reverse heart failure.

Question 83

In a patient with high-output heart failure caused by severe anemia, which laboratory finding is most likely to be elevated?

Answer 83

Hemoglobin and hematocrit ## Footnote In severe anemia, the heart attempts to meet oxygen demand, leading to high-output heart failure.

Question 84

What is the most likely cause of symptoms like shortness of breath and orthopnea?

Answer 84

Left-sided heart failure ## Footnote These symptoms are classic indicators of pulmonary congestion associated with left-sided heart failure.

Question 85

What is the most common cause of right-sided heart failure (RHF)?

Answer 85

Left-sided heart failure ## Footnote Backward pressure from a failing left ventricle is the primary cause of RHF.

Question 86

Which clinical finding is indicative of right-sided heart failure?

Answer 86

Jugular vein distension (JVD) ## Footnote JVD is a classic finding due to blood backing up into systemic veins in RHF.

Question 87

What is the most likely cause of hepatomegaly and peripheral edema in a patient with fluid retention?

Answer 87

Right-sided heart failure ## Footnote These are systemic signs of venous congestion caused by RHF.

Question 88

What beneficial effect do ACE inhibitors have on cardiac output (CO)?

Answer 88

Reduced blood pressure and afterload ## Footnote ACE inhibitors lower afterload, aiding the failing heart in pumping blood more efficiently.

Question 89

What is the primary benefit of diuretics for a patient with left-sided heart failure?

Answer 89

They reduce preload and fluid volume ## Footnote Diuretics decrease circulating volume, easing pulmonary symptoms in heart failure.

Question 90

Which hormone is most responsible for vasoconstriction and sodium retention in heart failure?

Answer 90

Aldosterone ## Footnote Aldosterone promotes sodium and water retention, increasing blood volume and pressure.

Question 91

What should the nurse be most concerned about in a patient experiencing increased JVD and peripheral edema?

Answer 91

Worsening of right-sided heart failure ## Footnote These signs indicate worsening systemic fluid overload due to RHF.

Question 92

Which symptom is most commonly associated with left-sided heart failure?

Answer 92

Shortness of breath and crackles in the lungs ## Footnote These symptoms indicate pulmonary congestion typical of left-sided heart failure.

Question 93

What findings would a nurse expect to find in a patient with right-sided heart failure?

Answer 93

Peripheral edema and ascites ## Footnote RHF causes systemic congestion, leading to fluid accumulation in tissues and the abdomen.

Question 94

What is the primary role of natriuretic peptides, such as BNP, in heart failure?

Answer 94

To counteract the effects of the SNS and RAAS ## Footnote BNP and ANP oppose vasoconstriction and fluid retention, helping reduce the burden of heart failure.

Question 95

What is the hallmark sign of systolic heart failure (HFrEF)?

Answer 95

Decreased ejection fraction (EF) ## Footnote Systolic heart failure is characterized by an EF of less than 40%.

Question 96

What is the most consistent condition for a patient who had a myocardial infarction and presents with heart failure symptoms?

Answer 96

Systolic heart failure (HFrEF) ## Footnote A recent MI can lead to ventricular dysfunction and reduced EF, indicating systolic heart failure.

Question 97

What should the nurse instruct a patient with left-sided heart failure who feels lightheaded upon standing?

Answer 97

Instruct the patient to avoid standing up quickly ## Footnote This helps prevent dizziness caused by rapid changes in blood pressure.

Question 98

What compensatory mechanism can initially improve cardiac output but may worsen heart failure?

Answer 98

Ventricular remodeling ## Footnote Ventricular remodeling can initially help but eventually leads to worsening heart failure.

Question 99

What is the most reliable indicator of fluid gain/loss in a patient with heart failure?

Answer 99

Daily weight measurement ## Footnote Monitoring daily weight is crucial for assessing fluid retention accurately.

Question 100

What complications should the nurse monitor for in a patient receiving ACE inhibitors and beta-blockers?

Answer 100

Hypotension and bradycardia ## Footnote These medications can lower blood pressure and heart rate significantly.

Question 101

What is the most likely cause of nausea and loss of appetite in a patient with right-sided heart failure?

Answer 101

Fluid retention in the abdominal area causing GI congestion ## Footnote RHF leads to systemic congestion, impacting gastrointestinal function.

Question 102

What intervention should be prioritized for a patient with left-sided heart failure presenting with severe shortness of breath?

Answer 102

Provide supplemental oxygen ## Footnote Oxygen helps alleviate hypoxia caused by pulmonary congestion.

Question 103

What is a critical aspect of managing a patient with right-sided heart failure and fluid retention?

Answer 103

Restricting sodium intake and administering diuretics ## Footnote This helps manage fluid overload and improve symptoms.

Question 104

What is the most likely underlying cause of right-sided heart failure in a patient with chronic pulmonary disease?

Answer 104

Cor pulmonale ## Footnote Cor pulmonale refers to right-sided heart failure resulting from lung disease.

Question 105

What symptoms would a nurse expect to find in a patient with left-sided heart failure?

Answer 105

Crackles and cough ## Footnote These symptoms indicate pulmonary congestion associated with left-sided heart failure.

Question 106

What is a primary risk factor for developing heart failure?

Answer 106

Chronic hypertension ## Footnote Chronic hypertension is a significant contributing factor to heart failure development.

Question 107

What is the primary role of vasopressin (ADH) in heart failure?

Answer 107

To increase sodium retention and vasoconstriction ## Footnote Vasopressin helps retain fluids and increases blood pressure, impacting heart failure management.

Question 108

What finding would suggest worsening of right-sided heart failure?

Answer 108

Increased jugular vein distension (JVD) ## Footnote Increased JVD indicates worsening systemic fluid overload in right-sided heart failure.

Question 109

Which clinical manifestation is most commonly seen in both systolic and diastolic heart failure?

Answer 109

Pulmonary congestion ## Footnote Both types of heart failure can lead to fluid backing up into the lungs.

Question 110

Which compensatory mechanism is most likely contributing to increasing fatigue and weakness in a patient with heart failure?

Answer 110

All of the above ## Footnote Ventricular dilation, sympathetic activation, and RAAS activation all contribute to heart failure symptoms.

Question 111

What lifestyle modification should be emphasized for a patient with heart failure?

Answer 111

Avoiding sodium-rich foods to help control fluid retention ## Footnote Limiting sodium intake is crucial for managing fluid retention in heart failure.

Question 112

What does paroxysmal nocturnal dyspnea indicate in a patient with left-sided heart failure?

Answer 112

Fluid accumulation in the lungs when the patient is lying down ## Footnote This symptom is caused by pulmonary congestion that occurs in a supine position.

Question 113

What is the most appropriate intervention for managing fluid retention in a patient with hypertension and left-sided heart failure?

Answer 113

Restrict sodium intake and administer diuretics ## Footnote This approach helps reduce fluid overload and manage heart failure symptoms.

Question 114

What is congestion in the context of heart failure?

Answer 114

Fluid leaks into tissues and abdomen ## Footnote This can lead to various symptoms and complications in heart failure patients.

Question 115

What is the role of BNP and ANP in heart failure?

Answer 115

They oppose vasoconstriction and fluid retention, helping reduce HF burden. ## Footnote BNP (B-type natriuretic peptide) and ANP (atrial natriuretic peptide) counteract the effects of the sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS).

Question 116

What is the hallmark of systolic heart failure (HFrEF)?

Answer 116

Decreased ejection fraction (EF) with EF < 40%. ## Footnote Systolic heart failure is characterized by the heart's inability to pump effectively.

Question 117

What can a recent myocardial infarction lead to?

Answer 117

Ventricular dysfunction and reduced EF, resulting in systolic heart failure. ## Footnote This is often referred to as heart failure with reduced ejection fraction (HFrEF).

Question 118

What should patients be instructed to avoid to prevent lightheadedness?

Answer 118

Standing up quickly. ## Footnote This may be due to orthostatic hypotension from volume loss.

Question 119

What is ventricular remodeling?

Answer 119

Initially boosts cardiac output but becomes harmful long-term, leading to poor contractility and HF progression. ## Footnote It refers to changes in the size, shape, and function of the heart after injury.

Question 120

What is the most sensitive and reliable indicator of fluid changes?

Answer 120

Daily weight measurement. ## Footnote Monitoring weight can help detect fluid retention early.

Question 121

What are potential side effects of ACE inhibitors and beta-blockers?

Answer 121

Hypotension and bradycardia. ## Footnote These medications lower blood pressure and heart rate, requiring close monitoring.

Question 122

What causes GI congestion in right heart failure?

Answer 122

Fluid retention in the abdominal area. ## Footnote This can lead to symptoms like anorexia and nausea.

Question 123

What is the first-line treatment for pulmonary edema?

Answer 123

Administer a diuretic. ## Footnote This helps reduce excess fluid in the lungs.

Question 124

What dietary restriction is important for managing heart failure?

Answer 124

Restricting sodium intake. ## Footnote Sodium worsens fluid retention, which is critical to manage in heart failure.

Question 125

What condition is characterized by right ventricular hypertrophy due to chronic lung disease?

Answer 125

Cor pulmonale. ## Footnote This can lead to right heart failure.

Question 126

What symptoms can indicate left heart failure?

Answer 126

Crackles and cough. ## Footnote These occur due to blood backing up into the lungs.

Question 127

How does chronic hypertension affect heart failure?

Answer 127

It increases afterload, making it harder for the heart to pump. ## Footnote This can lead to heart failure over time.

Question 128

What effect does ADH have in heart failure?

Answer 128

Increases sodium retention and vasoconstriction. ## Footnote This worsens fluid overload.

Question 129

What does increased jugular vein distension (JVD) indicate?

Answer 129

Increased right-sided pressure and worsening right heart failure. ## Footnote JVD is a clinical sign often assessed in heart failure patients.

Question 130

What can cause pulmonary congestion?

Answer 130

Both systolic and diastolic heart failure can cause pulmonary symptoms due to fluid backup. ## Footnote This leads to symptoms like shortness of breath.

Question 131

What mechanisms initially help heart failure but eventually worsen it?

Answer 131

Remodeling, SNS, RAAS. ## Footnote These compensatory mechanisms can lead to adverse outcomes in heart failure.

Question 132

What is a cornerstone of heart failure self-management?

Answer 132

Avoiding sodium-rich foods to help control fluid retention. ## Footnote This helps prevent fluid buildup.

Question 133

What causes paroxysmal nocturnal dyspnea (PND)?

Answer 133

Fluid shifts into lungs when lying down, leading to hypoxia. ## Footnote This can cause severe respiratory distress at night.

Question 134

What combination helps manage fluid overload in heart failure?

Answer 134

Restrict sodium intake and administer diuretics. ## Footnote This strategy is effective in controlling symptoms of heart failure.

Question 135

Which of the following is a characteristic of synovial joints (diarthroses)? A) They are immovable. B) They allow the greatest degree of movement. C) They are held together by fibrous connective tissue. D) They have no joint cavity.

Answer 135

B) They allow the greatest degree of movement.

Question 136

Which of the following is TRUE about synovial fluid? A) It provides oxygen to the cartilage. B) It lubricates the joint and reduces friction between articular surfaces. C) It is produced by the tendons surrounding the joint. D) It is produced by the articular cartilage itself.

Answer 136

B) It lubricates the joint and reduces friction between articular surfaces.

Question 137

Which of the following is an example of a ball-and-socket joint? A) Elbow B) Wrist C) Hip D) Knee

Answer 137

C) Hip

Question 138

What range of movements does a ball-and-socket joint like the shoulder allow? A) Flexion and extension only B) Only rotation C) A wide range of movements including flexion, extension, abduction, adduction, and rotation D) Only sliding movements

Answer 138

C) A wide range of movements including flexion, extension, abduction, adduction, and rotation.

Question 139

Which of the following is a function of the synovium (synovial membrane) in a synovial joint? A) Absorbs shock and reduces impact. B) Secretes synovial fluid for lubrication. C) Connects muscles to bones. D) Provides structural stability to the joint.

Answer 139

B) Secretes synovial fluid for lubrication.

Question 140

Which type of joint allows only rotational movement? A) Pivot joint B) Hinge joint C) Saddle joint D) Ball-and-socket joint

Answer 140

A) Pivot joint

Question 141

Which statement about bursae is correct? A) Bursae are small fluid-filled sacs that help absorb shock and reduce friction. B) Bursae are located only between bones and muscles. C) Bursae are found only in the knees and shoulders. D) Bursae are responsible for joint lubrication and nutrient supply.

Answer 141

A) Bursae are small fluid-filled sacs that help absorb shock and reduce friction.

Question 142

Which structure is most likely affected by total knee replacement surgery, leading to limited range of motion (ROM)? A) Ligaments B) Tendons C) Articular cartilage D) Synovial fluid

Answer 142

C) Articular cartilage

Question 143

Which joint allows for the movement of flexion, extension, abduction, adduction, and opposition? A) Saddle joint B) Hinge joint C) Condyloid joint D) Pivot joint

Answer 143

A) Saddle joint

Question 144

The hip joint is classified as which type of joint? A) Synarthrosis B) Diarthrosis C) Amphiarthrosis D) Cartilaginous

Answer 144

B) Diarthrosis

Question 145

Which of the following is the most common form of arthritis, characterized by joint pain, stiffness, and cartilage degeneration? A) Rheumatoid Arthritis (RA) B) Osteoarthritis (OA) C) Gout D) Juvenile Rheumatoid Arthritis (JRA)

Answer 145

B) Osteoarthritis (OA)

Question 146

Which non-drug therapy is most appropriate for a patient with osteoarthritis (OA)? A) Strict bed rest B) Weight loss and exercise C) High-intensity cardiovascular exercises D) Avoiding all forms of physical activity

Answer 146

B) Weight loss and exercise

Question 147

What is the primary cause of osteoarthritis (OA)? A) Autoimmune response B) Aging and genetic predisposition C) Deposition of urate crystals D) Joint injury from trauma

Answer 147

B) Aging and genetic predisposition

Question 148

Which joint is most commonly affected in patients with osteoarthritis? A) Elbow B) Ankle C) Knee D) Wrist

Answer 148

C) Knee

Question 149

Which characteristic is most consistent with the progression of rheumatoid arthritis (RA)? A) Pain worsens with rest and improves with activity B) Joint damage is usually unilateral and limited to weight-bearing joints C) Joint inflammation occurs symmetrically, typically affecting the small joints first D) Pain improves with the application of heat or cold therapy

Answer 149

C) Joint inflammation occurs symmetrically, typically affecting the small joints first

Question 150

What is a common complication associated with gout? A) Joint deformities and stiffness B) The deposition of urate crystals, typically affecting the big toe C) Chronic pain that worsens with rest D) The development of osteophytes (bone spurs) in the affected joints

Answer 150

B) The deposition of urate crystals, typically affecting the big toe

Question 151

What is the most appropriate initial drug treatment for pain management in a patient with osteoarthritis? A) Acetaminophen B) Methotrexate C) Corticosteroids D) Colchicine

Answer 151

A) Acetaminophen

Question 152

Which statement is TRUE regarding Juvenile Rheumatoid Arthritis (JRA)? A) It primarily affects adults and is characterized by symmetrical joint inflammation. B) It is an autoimmune disorder that typically affects children and may have a different course than adult rheumatoid arthritis. C) It is a degenerative condition resulting from cartilage wear and tear, like osteoarthritis. D) It typically presents with urate crystal deposition in the joints.

Answer 152

B) It is an autoimmune disorder that typically affects children and may have a different course than adult rheumatoid arthritis.

Question 153

What is the most likely reason for the development of posttraumatic arthritis? A) Aging and genetic predisposition B) Autoimmune processes C) Physical injury to a joint D) Excessive physical activity without rest

Answer 153

C) Physical injury to a joint

Question 154

Which imaging study is most commonly used to assess joint space narrowing and the presence of osteophytes in osteoarthritis? A) MRI B) X-ray C) CT scan D) Bone scan

Answer 154

B) X-ray

Question 155

What assessment is most important to confirm the diagnosis of Rheumatoid Arthritis (RA)? A) Joint aspiration (arthrocentesis) to analyze synovial fluid B) Radiologic imaging to assess bone erosions C) Serum C-reactive protein (CRP) levels D) Antinuclear Antibody (ANA) test to rule out lupus

Answer 155

A) Joint aspiration (arthrocentesis) to analyze synovial fluid

Question 156

Which nursing intervention is most important for a patient prescribed Methotrexate for RA? A) Instruct the patient to take the medication with food to minimize stomach irritation B) Encourage the patient to avoid crowds to reduce the risk of infection C) Teach the patient to take folic acid to prevent gastrointestinal side effects D) Recommend a high-protein diet to prevent liver toxicity

Answer 156

B) Encourage the patient to avoid crowds to reduce the risk of infection

Question 157

What is a hallmark sign of active Rheumatoid Arthritis (RA) during an exacerbation? A) Morning stiffness that resolves within 30 minutes B) Symmetrical joint pain and swelling in the upper extremities C) Severe joint pain after heavy physical activity D) Swelling and redness limited to one joint

Answer 157

B) Symmetrical joint pain and swelling in the upper extremities

Question 158

What is the most important intervention for a patient with RA presenting with dry mouth and eyes, suspected of having Sjögren’s syndrome? A) Monitor for signs of systemic infection B) Encourage increased fluid intake and provide oral lubricants C) Suggest a low-sodium diet to reduce fluid retention D) Educate the patient on joint protection techniques

Answer 158

B) Encourage increased fluid intake and provide oral lubricants

Question 159

What is the most important nursing action before initiating therapy with biologic response modifiers (BRMs) for RA? A) Assess the patient's blood glucose levels B) Perform a PPD test for tuberculosis (TB) C) Educate the patient on the risk of osteoporosis D) Check the patient’s liver function

Answer 159

B) Perform a PPD test for tuberculosis (TB)

Question 160

What should the nurse monitor for during corticosteroid therapy in a patient with RA experiencing acute pain? A) Hypoglycemia B) Symptoms of infection C) Dehydration D) Hypertension

Answer 160

B) Symptoms of infection

Question 161

What intervention should the nurse prioritize for a patient with RA who complains of fatigue and decreased activity tolerance? A) Encourage the patient to increase physical activity to build strength B) Teach the patient energy conservation techniques C) Suggest the patient reduce their medication dose to decrease fatigue D) Recommend the patient take naps throughout the day to rest

Answer 161

B) Teach the patient energy conservation techniques

Question 162

Which statement by a patient newly diagnosed with RA indicates a need for further teaching? A) "I will take my Methotrexate as prescribed to prevent joint damage." B) "I should expect my joints to get better as I take my medications." C) "I will avoid smoking since it can worsen my condition." D) "Physical therapy will help me maintain joint function."

Answer 162

B) "I should expect my joints to get better as I take my medications."

Question 163

What is the primary goal of total joint replacement (TJR) for a patient with RA? A) To completely cure rheumatoid arthritis B) To relieve pain and improve joint function C) To correct joint deformities D) To prevent further systemic complications

Answer 163

B) To relieve pain and improve joint function

Question 164

What is the primary goal of a synovectomy for a patient with RA? A) To decrease inflammation and preserve joint function B) To replace the damaged joint with an artificial prosthesis C) To correct bony ankylosis and restore range of motion D) To remove rheumatoid nodules from affected areas

Answer 164

A) To decrease inflammation and preserve joint function

Question 165

What is a potential complication of untreated RA that the nurse should monitor for? A) Osteoporosis B) Liver cirrhosis C) Acute renal failure D) Hyperthyroidism

Answer 165

A) Osteoporosis

Question 166

What is the most important aspect of patient education for a 60-year-old patient with RA concerned about long-term effects of Methotrexate? A) Avoid alcohol consumption to reduce liver toxicity B) Monitor blood glucose levels regularly C) Drink plenty of fluids to flush out the medication D) Wear sunscreen to prevent sunburn from medication sensitivity

Answer 166

A) Avoid alcohol consumption to reduce liver toxicity

Question 167

What complication can prolonged NSAID use lead to for a patient with RA? A) Liver failure B) Gastrointestinal bleeding C) Nephrotoxicity D) Anemia

Answer 167

B) Gastrointestinal bleeding

Question 168

What complication is a patient with RA on long-term corticosteroid therapy at increased risk for? A) Anemia B) Hypertension C) Hypokalemia D) Hyperthyroidism

Answer 168

B) Hypertension

Question 169

What laboratory finding is anticipated for a patient with RA experiencing severe fatigue and anemia? A) Increased red blood cell (RBC) count B) Decreased white blood cell (WBC) count C) Elevated erythrocyte sedimentation rate (ESR) D) Low platelet count

Answer 169

C) Elevated erythrocyte sedimentation rate (ESR)

Question 170

What is the most likely diagnosis for a 55-year-old female with joint pain that worsens with activity and improves with rest? A) Rheumatoid Arthritis (RA) B) Gout C) Osteoarthritis (OA) D) Systemic Lupus Erythematosus (SLE)

Answer 170

C) Osteoarthritis (OA)

Question 171

What is the most likely diagnosis for a patient with joint pain that worsens with activity and improves with rest?

Answer 171

C) Osteoarthritis (OA) ## Footnote OA is characterized by joint pain that worsens with activity and is relieved by rest, along with crepitus and joint stiffness.

Question 172

What is the most important teaching point for a patient prescribed acetaminophen (Tylenol) for OA?

Answer 172

B) "Make sure to avoid alcohol while taking this medication to prevent liver toxicity." ## Footnote Acetaminophen is metabolized by the liver, and alcohol use can increase the risk of liver damage.

Question 173

What is a common side effect of repeated corticosteroid injections in patients with OA?

Answer 173

B) Joint degeneration over time ## Footnote Repeated corticosteroid injections can lead to joint degeneration and increased risk of infection.

Question 174

Which dietary change should a nurse recommend to a patient with OA?

Answer 174

A) Increase intake of vitamin D to promote bone health ## Footnote Vitamin D helps maintain bone health and supports the immune system.

Question 175

What physical examination finding is characteristic of OA in the hands?

Answer 175

B) Presence of Heberden nodes at the distal interphalangeal (DIP) joints ## Footnote Heberden nodes are bony growths associated with OA and are commonly seen at the DIP joints.

Question 176

Fill in the blank: The cane should be placed on the _______ side of the affected leg.

Answer 176

opposite ## Footnote The cane should be used on the opposite side of the affected leg to provide support.

Question 177

What potential adverse effect should a nurse monitor for in a patient taking NSAIDs for OA?

Answer 177

C) GI irritation or bleeding ## Footnote NSAIDs can cause gastrointestinal irritation, ulcers, and bleeding, especially with long-term use.

Question 178

What is an appropriate energy conservation technique for a patient with OA?

Answer 178

A) "Pace your activities and take frequent rest breaks." ## Footnote Energy conservation techniques include pacing activities and taking breaks to avoid overexertion.

Question 179

What X-ray finding would indicate OA severity?

Answer 179

A) Joint space narrowing ## Footnote X-rays of OA typically show joint space narrowing due to cartilage loss.

Question 180

What is the most important intervention for a patient with OA and obesity?

Answer 180

B) Encourage weight loss to decrease mechanical stress on joints ## Footnote Weight loss is an effective strategy to manage OA symptoms.

Question 181

What non-pharmacologic intervention is appropriate for improving joint function in OA?

Answer 181

B) Engaging in low-impact activities like swimming or cycling ## Footnote Low-impact activities help improve joint mobility and strengthen muscles.

Question 182

What is the primary benefit of hyaluronic acid injections for OA?

Answer 182

B) They lubricate the joint, improving mobility and reducing pain ## Footnote Hyaluronic acid injections help provide lubrication to the joint.

Question 183

What indicates the need for further teaching regarding acetaminophen use in OA?

Answer 183

C) "I can take up to 5000 mg per day if I am not feeling relief." ## Footnote The maximum safe dose of acetaminophen is 4000 mg/day (ideally ≤3000 mg/day).

Question 184

What is the primary concern when administering tramadol to older adults?

Answer 184

B) The patient may experience dizziness, confusion, and falls ## Footnote Tramadol can cause CNS depression, increasing the risk of falls.

Question 185

What instruction is likely given to a patient taking NSAIDs for OA?

Answer 185

A) "Take NSAIDs with food to minimize gastrointestinal irritation." ## Footnote NSAIDs can cause GI irritation, so it is recommended to take them with food.

Question 186

What is the most significant risk of using opioid analgesics for OA pain?

Answer 186

C) Dependence and addiction ## Footnote Opioid analgesics carry a significant risk of dependence and addiction.

Question 187

What is a contraindication for hyaluronic acid injections?

Answer 187

A) History of skin infections at the injection site ## Footnote Hyaluronic acid injections should not be administered to patients with skin infections.

Question 188

What is the benefit of corticosteroid injections for OA flare-ups?

Answer 188

B) Quickly reducing inflammation during flare-ups ## Footnote Corticosteroid injections are effective for rapidly reducing inflammation.

Question 189

What is the most important nursing consideration for a patient using both acetaminophen and ibuprofen?

Answer 189

D) Both medications can increase the risk of gastrointestinal bleeding and renal impairment ## Footnote Combining acetaminophen and ibuprofen increases the risk of side effects.

Question 190

What is the primary concern when administering celecoxib (Celebrex) to a patient?

Answer 190

B) Risk of cardiovascular events such as myocardial infarction (MI) and stroke ## Footnote COX-2 inhibitors have been associated with an increased risk of cardiovascular events.

Question 191

What statement indicates a patient needs further education regarding corticosteroid injections?

Answer 191

B) "I can continue to receive corticosteroid injections regularly for long-term pain management." ## Footnote Corticosteroid injections should not be used frequently.

Question 192

What is the primary benefit of hyaluronic acid injections for osteoarthritis?

Answer 192

B) They lubricate the joint, improving mobility and reducing pain ## Footnote Hyaluronic acid injections help provide lubrication to the joint.

Question 193

What is the primary treatment for an acute gout attack?

Answer 193

C) Administering NSAIDs such as indomethacin to reduce inflammation ## Footnote NSAIDs are the first-line treatment for acute gout attacks.

Question 194

What is the primary action of allopurinol in managing gout?

Answer 194

B) Reduces the production of uric acid ## Footnote Allopurinol inhibits xanthine oxidase, reducing uric acid levels.

Question 195

What food should a patient with gout avoid to decrease the risk of future attacks?

Answer 195

B) Red meats, such as beef and lamb ## Footnote Red meats are high in purines, which can trigger gout attacks.

Question 196

What is the primary action of allopurinol in managing gout?

Answer 196

Reduces the production of uric acid. ## Footnote Allopurinol works by inhibiting xanthine oxidase, an enzyme involved in the production of uric acid.

Question 197

Which foods should a patient with gout avoid to decrease the risk of future attacks?

Answer 197

Red meats, such as beef and lamb. ## Footnote Red meats are high in purines, which are metabolized into uric acid and can exacerbate gout attacks.

Question 198

Which statement indicates a patient with gout needs further teaching?

Answer 198

I should eat more foods like red meat and organ meats to improve my health. ## Footnote Red meats and organ meats are high in purines, which can increase uric acid levels and trigger gout attacks.

Question 199

What adverse effects should a patient taking colchicine for gout be educated about?

Answer 199

Gastrointestinal side effects such as nausea, vomiting, and diarrhea. ## Footnote Colchicine is commonly associated with gastrointestinal side effects, particularly during an acute gout flare.

Question 200

What is the most appropriate intervention for a patient with a serum uric acid level of 9 mg/100 ml?

Answer 200

Assess the patient for signs of acute gout and initiate colchicine or NSAIDs. ## Footnote The presence of symptoms determines treatment for elevated uric acid levels.

Question 201

What is a major risk factor for secondary gout in a patient with renal insufficiency?

Answer 201

Reduced renal excretion of uric acid. ## Footnote In renal insufficiency, the kidneys are less able to excrete uric acid, leading to hyperuricemia and increased risk of gout.

Question 202

Why is hydration important for a patient with gout?

Answer 202

Hydration helps alkalinize the urine, preventing urate kidney stones. ## Footnote Proper hydration helps dilute uric acid in the urine and promotes its excretion.

Question 203

What should be monitored in a patient with gout taking probenecid?

Answer 203

Renal function, due to the risk of kidney stones. ## Footnote Probenecid increases the excretion of uric acid through the kidneys, which can lead to kidney stones.

Question 204

What is the nurse's most appropriate response to a patient with chronic gout who drinks coffee regularly?

Answer 204

You can continue drinking coffee, as it may help reduce uric acid levels. ## Footnote Some studies suggest that moderate coffee consumption may lower uric acid levels.

Question 205

What is the primary goal of kyphoplasty in a patient with a vertebral fracture?

Answer 205

To realign the vertebrae to prevent further compression. ## Footnote Kyphoplasty is a minimally invasive procedure used to treat vertebral compression fractures.

Question 206

What potential complication should be monitored in a patient receiving skeletal traction?

Answer 206

Pressure ulcers at the pin sites. ## Footnote Regular assessment of the pin sites is essential to prevent pressure ulcers.

Question 207

What is the most important intervention for preventing post-operative complications after hip fracture ORIF?

Answer 207

Applying a hip abduction pillow to prevent dislocation. ## Footnote A hip abduction pillow maintains proper alignment and prevents dislocation after hip surgery.

Question 208

What is a priority assessment for a patient in a cast after a wrist fracture?

Answer 208

Checking for neurovascular compromise (circulation, sensation, and motion). ## Footnote Neurovascular checks are critical to ensure blood flow and nerve function are intact.

Question 209

What complication is likely occurring in a patient with a femur fracture exhibiting severe pain, pallor, and tense swelling?

Answer 209

Acute compartment syndrome (ACS). ## Footnote ACS is characterized by the buildup of pressure within a muscle compartment, requiring immediate intervention.

Question 210

What is the purpose of a chlorhexidine shower in a pre-operative regimen for a hip fracture?

Answer 210

Reduce the risk of infection after surgery. ## Footnote Pre-operative cleansing with chlorhexidine helps minimize the risk of surgical site infections.

Question 211

What is acute compartment syndrome (ACS)?

Answer 211

ACS is characterized by the buildup of pressure within a muscle compartment, causing severe pain, swelling, and compromised circulation. It is a medical emergency requiring immediate intervention.

Question 212

What is the purpose of a chlorhexidine shower before surgery for a patient with a hip fracture?

Answer 212

To reduce the risk of infection after surgery.

Question 213

Which signs suggest a patient is experiencing fat embolism syndrome (FES)?

Answer 213

Sudden onset of shortness of breath and petechial rash.

Question 214

What should a nurse educate a patient with a Colles’ fracture to watch for?

Answer 214

Signs of swelling, color changes, or changes in sensation in the fingers.

Question 215

What is the first action a nurse should take for a patient with a humerus fracture showing external rotation deformity?

Answer 215

Assess for neurovascular compromise distal to the injury.

Question 216

What is the most important intervention to prevent complications of immobility post-surgery for a tibial fracture?

Answer 216

Encouraging early ambulation to promote circulation.

Question 217

What should be prioritized in the immediate post-operative period for a patient recovering from Total Knee Replacement (TKA)?

Answer 217

Apply ice packs to the knee to reduce swelling and manage pain.

Question 218

What should a nurse include in the care plan for a patient following total shoulder arthroplasty (TSA)?

Answer 218

Apply a shoulder immobilizer to prevent shoulder abduction immediately post-op.

Question 219

What should the nurse emphasize when using a Continuous Passive Motion (CPM) machine after Total Knee Arthroplasty (TKA)?

Answer 219

The patient should avoid knee flexion in bed by locking the knee in the CPM machine.

Question 220

Which intervention is critical when assessing neurovascular status post-operatively for a Total Knee Replacement (TKA)?

Answer 220

Check for circulation, sensation, and motion in the affected extremity.

Question 221

What action will best prevent an elderly patient with impaired vision from falling after a hip replacement?

Answer 221

Remove scatter rugs from the environment and install grab bars in the bathroom.

Question 222

What intervention should a nurse implement to minimize the risk of hip dislocation post-total hip replacement (THR)?

Answer 222

Instruct the patient to avoid crossing their legs at the knees.

Question 223

In the PULSES assessment, which domain is affected by limited upper extremity strength due to arthritis?

Answer 223

Upper Extremity Function.

Question 224

What should a nurse do to promote recovery for a post-operative Total Shoulder Arthroplasty (TSA) patient with a shoulder immobilizer?

Answer 224

Keep the affected shoulder immobilized in the shoulder immobilizer to prevent unnecessary movement.

Question 225

What intervention should be included for an elderly patient recovering from a total knee replacement with a history of confusion?

Answer 225

Use a bed alarm to alert staff when the patient attempts to get up unassisted.

Question 226

What is the most appropriate action for a nurse assessing a patient recovering from hip surgery with a burning sensation and inwardly turned foot?

Answer 226

Check for neurovascular compromise and notify the physician if symptoms persist.

Question 227

Which of the following is a primary cause of ischemic stroke? A) Rupture of a blood vessel B) Blood clot or embolism blocking a cerebral artery C) Decreased blood volume due to dehydration D) Inflammation of brain tissue

Answer 227

B) Blood clot or embolism blocking a cerebral artery

Question 228

What is the most common type of stroke? A) Hemorrhagic stroke B) Ischemic stroke C) Subdural hematoma D) Transient ischemic attack (TIA)

Answer 228

B) Ischemic stroke

Question 229

The goal of treatment for ischemic stroke is to: A) Control blood pressure to prevent a hemorrhage B) Remove the embolus using a clot-busting drug C) Relieve pressure on the brain caused by swelling D) Stop the bleeding from a ruptured aneurysm

Answer 229

B) Remove the embolus using a clot-busting drug

Question 230

Which of the following is NOT a risk factor for stroke? A) Hypertension B) High cholesterol C) Regular exercise D) Atrial fibrillation

Answer 230

C) Regular exercise

Question 231

Which type of stroke is most likely caused by high blood pressure or an aneurysm? A) Ischemic stroke B) Embolic stroke C) Hemorrhagic stroke D) Transient ischemic attack (TIA)

Answer 231

C) Hemorrhagic stroke

Question 232

Which of the following is a symptom of a left-sided cerebrovascular accident (CVA)? A) Hemianopsia in the left visual field B) Impaired verbal communication C) Right-sided neglect D) Difficulty with spatial orientation

Answer 232

B) Impaired verbal communication

Question 233

What is the primary goal of treatment for a hemorrhagic stroke? A) Reperfuse brain tissue B) Control bleeding and stop the rupture C) Lower blood pressure to prevent further ischemia D) Remove blood clots using thrombolytics

Answer 233

B) Control bleeding and stop the rupture

Question 234

What should be administered to a patient with an ischemic stroke within the first 3 hours? A) Tissue plasminogen activator (tPA) B) Antihypertensive medications C) Anticoagulants like heparin D) Diuretics to reduce swelling

Answer 234

A) Tissue plasminogen activator (tPA)

Question 235

Which of the following is a symptom of increased intracranial pressure (ICP)? A) Hyperventilation B) Decreased blood pressure C) Sluggish pupil response to light D) Decreased heart rate

Answer 235

C) Sluggish pupil response to light

Question 236

A patient experiencing a transient ischemic attack (TIA) is at an increased risk for: A) Seizures B) Permanent neurological damage C) Having a full-blown stroke in the next 2-5 years D) Respiratory failure

Answer 236

C) Having a full-blown stroke in the next 2-5 years

Question 237

Which of the following is a contraindication for the administration of tPA (tissue plasminogen activator)? A) Blood pressure of 160/100 B) Onset of symptoms within 3 hours C) History of transient ischemic attack D) Age of 65 years or older

Answer 237

A) Blood pressure of 160/100

Question 238

Which of the following is the correct nursing intervention when caring for a patient with aphasia? A) Encourage the patient to finish their sentences B) Speak to the patient quickly to reduce anxiety C) Use simple, clear sentences and speak slowly D) Ignore the patient's attempts to communicate

Answer 238

C) Use simple, clear sentences and speak slowly

Question 239

What is a major concern for patients recovering from a stroke with dysphagia? A) Hyperglycemia B) Aspiration pneumonia C) Increased intracranial pressure D) Seizures

Answer 239

B) Aspiration pneumonia

Question 240

The nurse is assessing a patient who had a right-sided cerebrovascular accident (CVA). The patient is unaware of their left side and has difficulty judging distances. This is known as: A) Right-sided neglect B) Left-sided neglect C) Hemianopsia D) Apraxia

Answer 240

A) Right-sided neglect

Question 241

When a patient has an ischemic stroke, what is the priority diagnostic test to perform? A) MRI B) CT scan without contrast C) EEG D) Brain angiography

Answer 241

B) CT scan without contrast

Question 242

A patient has been diagnosed with a subdural hematoma following a stroke. Which of the following treatments would most likely be indicated? A) Anticoagulants to dissolve the clot B) A craniotomy to relieve pressure C) Tissue plasminogen activator (tPA) to dissolve the clot D) Administration of high-dose corticosteroids

Answer 242

B) A craniotomy to relieve pressure

Question 243

A nurse is performing a swallow screen for a stroke patient. Which of the following signs indicates that the patient has failed the swallow screen? A) No coughing or choking during the test B) Coughing or choking while swallowing C) Larynx rises normally when swallowing D) No signs of aspiration observed

Answer 243

B) Coughing or choking while swallowing

Question 244

Which of the following symptoms is most likely associated with a stroke affecting the left hemisphere of the brain? A) Neglect syndrome B) Impaired verbal communication C) Spatial disorientation D) Emotional lability

Answer 244

B) Impaired verbal communication

Question 245

Which medication is commonly prescribed to prevent the recurrence of ischemic stroke in patients with atrial fibrillation? A) Tissue plasminogen activator (tPA) B) Anticoagulants (e.g., warfarin) C) Antihypertensive medications D) Corticosteroids

Answer 245

B) Anticoagulants (e.g., warfarin)

Question 246

A stroke patient presents with weakness on the right side of the body, and difficulty with speech. Which part of the brain was likely affected? A) Right hemisphere B) Left hemisphere C) Cerebellum D) Brainstem

Answer 246

B) Left hemisphere

Question 247

A nurse is preparing to change the dressing of a post-operative wound that is healing by primary intention. Which of the following should the nurse expect? A) Granulation tissue formation in the wound bed B) Edges of the wound are approximated and closed C) Significant drainage from the wound D) Presence of eschar on the wound surface

Answer 247

B) Edges of the wound are approximated and closed

Question 248

A patient is receiving care for a surgical wound that has become infected. Which drainage type would you most likely observe? A) Sanguineous B) Serosanguineous C) Purulent D) Serous

Answer 248

C) Purulent

Question 249

A nurse is using sterile technique to insert a Foley catheter. Which of the following principles of surgical asepsis should be followed? A) The nurse should assume that any item that is sterile remains sterile until used B) The sterile field is considered contaminated if it is below waist level C) A sterile field remains sterile as long as it is covered by a dressing D) It is safe to touch sterile items with unsterile hands if wearing gloves

Answer 249

B) The sterile field is considered contaminated if it is below waist level

Question 250

A nurse is preparing to perform a dressing change on a wound that is healing by secondary intention. Which characteristic should the nurse anticipate finding in the wound bed? A) Closed wound edges with no drainage B) Formation of new granulation tissue and drainage C) Necrotic tissue that needs to be debrided D) Clear fluid filling the wound space

Answer 250

B) Formation of new granulation tissue and drainage

Question 251

When performing a wound assessment, the nurse documents a large amount of thick yellow drainage from the wound. This is most consistent with which type of drainage? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

Answer 251

D) Purulent

Question 252

A nurse is caring for a patient with a full-thickness wound. Which statement correctly describes the healing process for this type of wound? A) The wound will re-epithelialize rapidly B) Granulation tissue will form to fill the wound bed C) It will heal in 5–7 days with minimal scarring D) The wound will heal only by primary intention

Answer 252

B) Granulation tissue will form to fill the wound bed

Question 253

A patient has been receiving wound care for a laceration that has become infected. The nurse should apply which of the following to promote the formation of good granulation tissue? A) Topical antimicrobial ointment B) Moisture barrier cream C) Dry sterile dressing D) Heat therapy

Answer 253

A) Topical antimicrobial ointment

Question 254

During a wound dressing change, a nurse notices black eschar covering the wound bed. What is the appropriate nursing action? A) Apply an antimicrobial dressing and continue observation B) Leave the eschar intact as it will naturally fall off C) Perform debridement, as necrotic tissue inhibits healing D) Clean the wound with hydrogen peroxide to remove debris

Answer 254

C) Perform debridement, as necrotic tissue inhibits healing

Question 255

A nurse is explaining the importance of wound nutrition to a post-operative patient. Which of the following should the nurse emphasize? A) Hydration promotes collagen and epithelialization B) Malnutrition increases the risk for wound infection C) Increased vitamin E is necessary to prevent wound dehiscence D) The intake of sugars accelerates wound healing

Answer 255

B) Malnutrition increases the risk for wound infection

Question 256

A patient’s wound is showing signs of dehiscence. The nurse should perform which of the following actions first? A) Place the patient in a low Fowler’s position B) Apply a dry dressing to the wound C) Notify the healthcare provider and stay with the patient D) Increase the patient’s fluid intake to promote healing

Answer 256

C) Notify the healthcare provider and stay with the patient

Question 257

Which of the following is the correct principle when performing a surgical hand wash? A) Wash only the palms and the front of the hands B) Keep hands and forearms below elbow level to avoid contamination C) Clean under fingernails and between fingers for at least 2 minutes D) Apply alcohol-based hand rub after rinsing hands with water

Answer 257

C) Clean under fingernails and between fingers for at least 2 minutes

Question 258

A nurse is caring for a patient with a pressure ulcer that has a black, necrotic area. Which type of wound healing will most likely occur? A) Primary intention B) Secondary intention C) Tertiary intention D) Partial thickness healing

Answer 258

B) Secondary intention

Question 259

A nurse is caring for a patient with a draining surgical wound that is healing by tertiary intention. Which of the following is most characteristic of this type of healing? A) The wound is closed immediately after surgery B) The wound is initially left open and closed later after observation C) Granulation tissue forms and fills the wound bed immediately D) The wound heals rapidly without drainage

Answer 259

B) The wound is initially left open and closed later after observation

Question 260

What is the nurse’s priority action when a wound dressing is saturated with drainage? A) Change the dressing immediately B) Apply a pressure bandage to the wound C) Reinforce the dressing and notify the healthcare provider D) Clean the wound with saline and apply a new sterile dressing

Answer 260

C) Reinforce the dressing and notify the healthcare provider

Question 261

A nurse is teaching a patient about heat therapy for wound healing. Which of the following is an appropriate contraindication for heat therapy? A) Joint stiffness B) Muscle spasm C) Open wounds D) Pain relief

Answer 261

C) Open wounds

Question 262

A nurse notices that a patient's wound has signs of infection. The drainage is purulent and foul-smelling. What should be the nurse's next step? A) Apply a dry dressing to the wound B) Clean the wound with normal saline and apply an antimicrobial dressing C) Document the findings and monitor for changes in vital signs D) Perform wound debridement immediately

Answer 262

B) Clean the wound with normal saline and apply an antimicrobial dressing

Question 263

Which of the following is a critical aspect of maintaining surgical asepsis during a dressing change? A) Use only non-sterile gloves when handling dressings B) Never leave a sterile field unattended C) Ensure sterile objects are touched by unsterile items for cleaning D) Touch sterile objects with unsterile hands to adjust placement

Answer 263

B) Never leave a sterile field unattended

Question 264

A nurse is preparing to administer sublingual nitroglycerin. Which of the following is an example of medical asepsis? A) Using sterile gloves to administer the medication B) Disinfecting the area before administration C) Ensuring the medication is free of microorganisms D) Maintaining a sterile field during medication administration

Answer 264

B) Disinfecting the area before administration

Question 265

Which type of wound is most likely to result from an accidental knife injury with a clean, even edge? A) Laceration B) Incised C) Abraded D) Puncture

Answer 265

B) Incised

Question 266

A nurse is caring for a patient with a wound that is healing by secondary intention. What is the best intervention to promote healing? A) Keep the wound open and dry to promote scab formation B) Maintain a moist environment to facilitate granulation tissue formation C) Avoid dressing changes to prevent disturbing the healing process D) Apply heat therapy to reduce inflammation and swelling

Answer 266

B) Maintain a moist environment to facilitate granulation tissue formation

Question 267

A patient with a pressure ulcer is being treated with a vacuum-assisted closure (VAC) system. What is the primary purpose of this treatment? A) To provide moisture to the wound bed B) To remove excess fluid and bacteria from the wound C) To keep the wound bed exposed to air for faster healing D) To debride necrotic tissue from the wound bed

Answer 267

B) To remove excess fluid and bacteria from the wound

Question 268

A nurse is assessing a wound for signs of infection. Which of the following would be the first indication of wound infection? A) Increased redness and swelling around the wound B) Pus-like drainage from the wound C) Presence of a foul odor from the wound D) Wound edges pulling apart

Answer 268

A) Increased redness and swelling around the wound

Question 269

A nurse is caring for a patient post-operatively and notices that the wound is gaping, with some of the internal organs protruding. What is the priority action? A) Apply a clean dressing and monitor the patient for shock B) Attempt to push the organs back into the wound C) Administer pain medications and call the surgeon D) Cover the wound with a sterile saline dressing and notify the healthcare provider

Answer 269

D) Cover the wound with a sterile saline dressing and notify the healthcare provider

Question 270

Which factor is most likely to impair wound healing in a diabetic patient? A) Increased blood sugar levels B) Adequate hydration C) High levels of vitamin C D) Regular exercise

Answer 270

A) Increased blood sugar levels

Question 271

A nurse is explaining the importance of protein in wound healing to a patient. Which of the following is the rationale for this? A) Protein enhances collagen production and tissue repair B) Protein increases circulation to the wound site C) Protein helps to reduce infection in the wound D) Protein reduces inflammation around the wound site

Answer 271

A) Protein enhances collagen production and tissue repair

Question 272

A nurse is caring for a post-surgical wound that has excessive drainage. Which type of drainage indicates fresh, active bleeding? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

Answer 272

B) Sanguineous

Question 273

A nurse is performing a dressing change on a wound with a surgical drain in place. Which step is most important to prevent contamination? A) Use a sterile technique to clean the drain site B) Apply the dressing before removing the old one C) Clean the wound and surrounding skin with alcohol D) Remove the old dressing and drain at the same time

Answer 273

A) Use a sterile technique to clean the drain site

Question 274

A nurse is caring for an elderly patient with a wound. Which of the following is the most likely factor affecting the patient's wound healing? A) Increased collagen production B) Decreased immune function C) Higher levels of growth factors D) Increased vascularity

Answer 274

B) Decreased immune function

Question 275

Which is the appropriate nursing action when a patient experiences a hematoma after surgery? A) Apply heat therapy to reduce swelling B) Monitor for signs of hemorrhage and notify the healthcare provider C) Apply pressure to the area to promote clotting D) Massaging the area to prevent blood pooling

Answer 275

B) Monitor for signs of hemorrhage and notify the healthcare provider

Question 276

A nurse is applying a dry sterile dressing to a wound. Which of the following is the primary purpose of this dressing? A) To keep the wound moist to promote faster healing B) To absorb exudate and protect the wound from contamination C) To provide a warm environment for the wound to heal D) To stimulate granulation tissue formation in the wound bed

Answer 276

B) To absorb exudate and protect the wound from contamination

Question 277

A nurse is assessing a patient with pneumonia. Which of the following symptoms would the nurse expect to find? A) Weight loss and fatigue B) Dyspnea, sputum, and chest pain C) Clear lung sounds and normal breathing D) Tachycardia and no cough

Answer 277

B) Dyspnea, sputum, and chest pain

Question 278

A patient with silicosis is being discharged. What should the nurse include in teaching about disease management? A) Smoking cessation, using inhalers B) Removal from exposure, oxygen therapy, and potential lung transplant C) Increased fluid intake to loosen mucus D) Use of antibiotics to treat infections

Answer 278

B) Removal from exposure, oxygen therapy, and potential lung transplant

Question 279

Which of the following statements is true regarding the pneumococcal vaccine for preventing pneumonia? A) The pneumococcal vaccine is given every 10 years for all adults B) The vaccine is recommended only for patients with asthma C) It is recommended every 5 years for individuals at risk D) Pneumonia vaccines are only effective in elderly populations

Answer 279

C) It is recommended every 5 years for individuals at risk

Question 280

A nurse is teaching a patient with asthma about self-management. Which of the following should the nurse emphasize? A) Avoid using the rescue inhaler frequently B) Monitor peak flow and use inhaler before exercise C) Increase fluid intake to thin mucus D) Continue smoking to build tolerance to triggers

Answer 280

B) Monitor peak flow and use inhaler before exercise

Question 281

Which of the following is a common trigger for asthma attacks? A) Excessive exercise in warm weather B) Exposure to allergens like dust, pet dander, and pollen C) Consuming foods rich in vitamin C D) Drinking cold beverages

Answer 281

B) Exposure to allergens like dust, pet dander, and pollen

Question 282

A patient with asthma is experiencing an exacerbation. What is the nurse's priority action? A) Administer a bronchodilator (rescue inhaler) B) Encourage the patient to take deep breaths C) Prepare the patient for a chest X-ray D) Perform a thorough history to identify triggers

Answer 282

A) Administer a bronchodilator (rescue inhaler)

Question 283

A nurse is caring for a patient with COPD. Which of the following assessment findings is most consistent with the disease? A) Dry cough and minimal sputum production B) Barrel chest and use of accessory muscles C) Sudden onset of dyspnea and cough D) Cyanosis only after physical activity

Answer 283

B) Barrel chest and use of accessory muscles

Question 284

The nurse is educating a patient with COPD about oxygen therapy. Which of the following is the appropriate guideline for administering oxygen to a COPD patient? A) Administer oxygen via non-rebreather mask at high flow rates B) Titrate oxygen to maintain SpO2 between 88-92% C) Use nasal cannula at 6–10 L/min to improve oxygenation D) Administer oxygen to achieve 100% saturation at all times

Answer 284

B) Titrate oxygen to maintain SpO2 between 88-92%

Question 285

The nurse is caring for a patient with emphysema. Which of the following findings is most likely? A) Clear lung sounds and normal lung expansion B) Barrel chest, decreased breath sounds, and dyspnea C) Productive cough with thick yellow sputum D) Presence of coarse crackles and wheezing

Answer 285

B) Barrel chest, decreased breath sounds, and dyspnea

Question 286

Which of the following is an expected finding in a patient with pneumonia? A) Fine crackles at the base of the lungs B) Decreased tactile fremitus C) Diminished breath sounds on auscultation D) Wheezing with prolonged exhalation

Answer 286

A) Fine crackles at the base of the lungs

Question 287

Which of the following actions should the nurse take when caring for a patient with a tracheostomy? A) Suction the tracheostomy tube for a maximum of 10 minutes B) Ensure a tracheostomy tray is at the bedside at all times C) Place the patient in a supine position for tracheostomy care D) Clean the inner cannula with hydrogen peroxide daily

Answer 287

B) Ensure a tracheostomy tray is at the bedside at all times

Question 288

A nurse is caring for a patient with hypoxemia. Which of the following should the nurse monitor to assess the patient’s oxygenation status? A) Pulse oximetry and arterial blood gases (ABGs) B) Heart rate and blood pressure only C) Respiratory rate and temperature D) Hemoglobin and hematocrit levels

Answer 288

A) Pulse oximetry and arterial blood gases (ABGs)

Question 289

A patient with COPD is receiving oxygen therapy. Which of the following should the nurse monitor for potential complications? A) Oxygen toxicity B) Hyperventilation C) Excessive fluid retention D) Oxygen deprivation in the brain

Answer 289

A) Oxygen toxicity

Question 290

A patient with COPD presents with respiratory distress and a low SpO2 level. What is the most appropriate nursing intervention? A) Administer oxygen via nasal cannula at 2 L/min B) Place the patient in a supine position for comfort C) Increase the oxygen flow rate to 10 L/min via non-rebreather mask D) Administer oxygen to achieve 100% saturation

Answer 290

A) Administer oxygen via nasal cannula at 2 L/min

Question 291

The nurse is performing an assessment of a patient with asthma. Which of the following findings would the nurse expect to observe during an asthma attack? A) Decreased wheezing and normal breath sounds B) Increased use of accessory muscles and expiratory wheezing C) Prolonged inspiration without wheezing D) Silent chest with no breath sounds

Answer 291

B) Increased use of accessory muscles and expiratory wheezing

Question 292

A nurse is caring for a patient with TB. Which of the following interventions should be included in the patient’s care plan? A) Place the patient in a private room with negative pressure B) Use a simple mask for oxygen administration C) Provide antibiotic therapy only when symptoms worsen D) Have the patient wear a non-rebreather mask at all times

Answer 292

A) Place the patient in a private room with negative pressure

Question 293

A nurse is caring for a patient with an obstructive disease. Which of the following is characteristic of obstructive diseases? A) Decreased airway resistance and difficulty inhaling B) Difficulty exhaling and air trapping C) Decreased lung volumes and reduced lung expansion D) Decreased sputum production and inflammation

Answer 293

B) Difficulty exhaling and air trapping

Question 294

Which of the following is an appropriate nursing action for a patient with hypoxia? A) Encourage the patient to breathe slowly and deeply to increase O2 intake B) Maintain the patient on 100% oxygen at all times C) Administer oxygen based on ABG results, aiming for 88–92% SpO2 D) Use a nasal cannula at 6 L/min for all patients with hypoxia

Answer 294

C) Administer oxygen based on ABG results, aiming for 88–92% SpO2

Question 295

Which of the following is true regarding the use of a non-rebreather mask (NRB)? A) The mask delivers oxygen at a rate of 10-15 L/min and provides 95-100% O2 B) The mask should be used for patients with COPD C) It is the preferred method for long-term oxygen therapy D) The mask can be used for any patient with low oxygen saturation

Answer 295

A) The mask delivers oxygen at a rate of 10-15 L/min and provides 95-100% O2

Question 296

The nurse is providing discharge instructions for a patient with chronic bronchitis. Which of the following should the nurse include in the education? A) Emphasize the importance of smoking cessation B) Encourage the patient to increase fluid intake to thin mucus C) Instruct the patient to avoid all forms of exercise D) Advise the patient to use bronchodilators only when needed

Answer 296

A) Emphasize the importance of smoking cessation

Question 297

A nurse is caring for a patient with pneumonia. Which diagnostic test would be most helpful in confirming the diagnosis? A) Chest X-ray B) Arterial blood gas (ABG) C) Pulmonary function tests (PFT) D) Sputum culture

Answer 297

A) Chest X-ray

Question 298

Which of the following is true regarding the pathophysiology of emphysema? A) There is inflammation and thickened mucus in the airways B) It is characterized by alveolar collapse and air trapping C) The primary cause is bacterial infection D) The disease leads to an increase in lung elasticity

Answer 298

B) It is characterized by alveolar collapse and air trapping

Question 299

Which of the following is a primary goal of treatment for a patient with COPD? A) Increase lung volume B) Decrease airway resistance and improve airflow C) Eliminate the need for oxygen therapy D) Promote rapid healing of the alveolar tissue

Answer 299

B) Decrease airway resistance and improve airflow

Question 300

The nurse is assessing an elderly patient with a history of pneumonia. Which of the following findings would be a concern? A) Increased respiratory rate and oxygen saturation of 95% B) Sudden onset of confusion, increased sputum production, and dyspnea C) Normal lung sounds with no wheezing or crackles D) Clear breath sounds with no signs of respiratory distress

Answer 300

B) Sudden onset of confusion, increased sputum production, and dyspnea

Question 301

A patient has been diagnosed with restrictive lung disease. Which of the following is a characteristic of this type of disease? A) Difficulty exhaling air and air trapping B) Reduced lung volumes and stiff lungs C) Chronic inflammation and increased mucus production D) Increased airflow and barrel chest formation

Answer 301

B) Reduced lung volumes and stiff lungs

Question 302

The nurse is caring for a patient with asthma. What is the primary purpose of a rescue inhaler? A) To provide a continuous supply of medication to prevent attacks B) To relieve bronchospasm and acute symptoms during an attack C) To monitor peak flow rates for long-term management D) To reduce airway resistance during physical activity

Answer 302

B) To relieve bronchospasm and acute symptoms during an attack

Question 303

A nurse is caring for a patient with hypoxia. Which of the following symptoms would be most indicative of this condition? A) Confusion and cyanosis B) Tachycardia and increased blood pressure C) Decreased respiratory rate and restlessness D) Hypotension and decreased oxygen demand

Answer 303

A) Confusion and cyanosis

Question 304

Which of the following is a common complication of long-term oxygen therapy? A) Oxygen toxicity B) Respiratory alkalosis C) Hypoventilation D) Respiratory acidosis

Answer 304

A) Oxygen toxicity

Question 305

A patient is being admitted with suspected TB. What should the nurse immediately implement to prevent transmission? A) Start the patient on a broad-spectrum antibiotic B) Place the patient on droplet precautions in a negative pressure room C) Administer oxygen via nasal cannula at 6 L/min D) Prepare the patient for a bronchoscopy

Answer 305

B) Place the patient on droplet precautions in a negative pressure room

Question 306

A patient with a tracheostomy is showing signs of respiratory distress. Which action is the nurse’s priority? A) Perform suctioning using sterile technique B) Increase the oxygen flow rate to 10 L/min C) Assist the patient into a sitting position D) Call the healthcare provider immediately

Answer 306

A) Perform suctioning using sterile technique

Question 307

Include all answer choices in the question (a through D) INCLUDE ALL ANSWER CHOICES IN THE QUESTION. A 65-year-old male patient is admitted with benign prostatic hyperplasia (BPH). He complains of weak urine stream and dribbling. Which of the following is a priority nursing intervention? A) Administer antibiotics as prescribed B) Monitor for urinary retention and bladder distension C) Instruct the patient to increase fluid intake D) Prepare the patient for a prostate biopsy

Answer 307

B) Monitor for urinary retention and bladder distension

Question 308

A nurse is educating a patient with urge incontinence about lifestyle modifications. Which of the following recommendations is most appropriate? A) "Limit fluid intake to prevent bladder overdistension." B) "Perform pelvic floor exercises regularly to strengthen the bladder muscles." C) "Avoid using a bathroom schedule to allow natural voiding urges to occur." D) "Increase caffeine and alcohol intake to help with bladder spasms."

Answer 308

B) "Perform pelvic floor exercises regularly to strengthen the bladder muscles."

Question 309

A patient post-TURP (Transurethral Resection of Prostate) surgery is experiencing discomfort. Which of the following should the nurse monitor for? A) Excessive bleeding and hematuria B) Elevated blood pressure and respiratory rate C) Fever and increased heart rate D) Distended abdomen and absence of bowel sounds

Answer 309

A) Excessive bleeding and hematuria

Question 310

A patient with diverticulitis is complaining of severe left lower quadrant pain, fever, and nausea. Which diagnostic test would the nurse expect the healthcare provider to order? A) Abdominal ultrasound B) CT scan of the abdomen C) Colonoscopy D) Barium swallow

Answer 310

B) CT scan of the abdomen

Question 311

A 70-year-old male is being treated for a urinary tract infection (UTI) post-surgery. He is confused, febrile, and hypotensive. The nurse suspects which complication? A) Pyelonephritis B) Urosepsis C) Bladder cancer D) Benign prostatic hyperplasia (BPH)

Answer 311

B) Urosepsis

Question 312

Which of the following is a common cause of overflow incontinence? A) Increased intra-abdominal pressure B) Bladder spasms C) Enlarged prostate or neurogenic bladder D) Urgency related to caffeine consumption

Answer 312

C) Enlarged prostate or neurogenic bladder

Question 313

A patient is diagnosed with diverticulosis. The nurse knows that the most effective intervention to prevent complications of diverticulosis is: A) Laxative use B) High-fiber diet C) Regular abdominal massage D) Use of enemas

Answer 313

B) High-fiber diet

Question 314

A nurse is caring for a patient who had a recent TURP procedure. Which of the following is a primary concern for this patient? A) Risk for hemorrhage and clot retention B) Risk for infection and electrolyte imbalance C) Risk for hypotension and dysrhythmias D) Risk for deep vein thrombosis (DVT)

Answer 314

A) Risk for hemorrhage and clot retention

Question 315

A patient with a history of urinary incontinence is being assessed for stress incontinence. Which of the following findings would support this diagnosis? A) Leakage with coughing or sneezing B) Sudden and intense urge to urinate C) Leakage during sleep D) Inability to urinate despite feeling the urge

Answer 315

A) Leakage with coughing or sneezing

Question 316

A nurse is teaching a patient with functional incontinence. Which of the following would be the most important focus of the teaching? A) Increasing fluid intake to prevent dehydration B) The need for medications to reduce bladder spasms C) Using assistive devices and regular bathroom access D) Performing pelvic floor exercises regularly

Answer 316

C) Using assistive devices and regular bathroom access

Question 317

A patient with BPH is being prepared for TURP surgery. Which of the following actions should the nurse take immediately postoperatively? A) Administer a high-fiber diet to prevent constipation B) Monitor for bleeding and the presence of clots in the urine C) Educate the patient on the importance of avoiding fluids D) Encourage the patient to perform deep breathing exercises

Answer 317

B) Monitor for bleeding and the presence of clots in the urine

Question 318

A nurse is caring for a patient with a nasoenteric tube for enteral feeding. The patient is at risk for which of the following complications? A) Refeeding syndrome B) Urinary retention C) Deep vein thrombosis D) Pseudomembranous colitis

Answer 318

A) Refeeding syndrome

Question 319

A patient is diagnosed with diverticulitis. Which of the following actions should the nurse prioritize in the care plan during the acute phase? A) Administering a high-fiber diet B) Encouraging fluid intake and ambulation C) Providing a low-fiber, clear liquid diet D) Administering oral laxatives as prescribed

Answer 319

C) Providing a low-fiber, clear liquid diet

Question 320

The nurse is caring for a patient with overflow incontinence. Which of the following would be an expected finding in this patient? A) Urinary frequency with small amounts of urine B) Constant dribbling of urine without the sensation of urgency C) Sudden strong urge to urinate followed by leakage D) Incontinence associated with coughing or laughing

Answer 320

B) Constant dribbling of urine without the sensation of urgency

Question 321

A patient with acute diverticulitis is experiencing nausea, vomiting, and lower abdominal pain. The nurse should first: A) Administer an antiemetic as prescribed B) Initiate a high-fiber diet C) Administer a stool softener D) Monitor vital signs and perform a physical assessment

Answer 321

D) Monitor vital signs and perform a physical assessment

Question 322

A patient who is post-TURP reports a sudden increase in bloody urine and clots. What is the nurse’s first action? A) Increase intravenous fluids B) Notify the healthcare provider C) Assess the patient's vital signs D) Administer a dose of analgesics

Answer 322

C) Assess the patient's vital signs

Question 323

A nurse is educating a patient with urge incontinence on management strategies. Which of the following should be included? A) Drink large quantities of water to dilute urine B) Increase intake of caffeine to stimulate bladder contraction C) Use bladder training techniques and scheduled voiding D) Limit fluid intake to prevent bladder distention

Answer 323

C) Use bladder training techniques and scheduled voiding

Question 324

Which of the following is a major risk factor for developing urinary tract infections (UTIs) in older adults? A) Dehydration and low fluid intake B) Use of high-dose corticosteroids C) Chronic constipation D) Long-term catheter use

Answer 324

D) Long-term catheter use

Question 325

A patient with diverticulitis has a fever, left lower quadrant pain, and abdominal tenderness. Which of the following diagnostic tests would be most helpful in confirming the diagnosis? A) Abdominal X-ray B) CT scan of the abdomen C) Colonoscopy D) Barium enema

Answer 325

B) CT scan of the abdomen

Question 326

A patient is recovering from a TURP procedure. Which of the following should be included in the discharge instructions? A) "Avoid drinking fluids for the next 24 hours." B) "You may resume normal activity immediately." C) "You may experience some mild, intermittent bleeding and clots in your urine." D) "Restrict your fluid intake to reduce urinary frequency."

Answer 326

C) "You may experience some mild, intermittent bleeding and clots in your urine."

Question 327

A nurse is assessing a patient with a history of BPH and recent TURP surgery. Which of the following findings would require immediate attention? A) Mild discomfort and dark red urine B) Sudden increase in bright red bleeding and clot formation C) Absence of urinary output for more than 4 hours D) Urine output with sediment and small clots

Answer 327

B) Sudden increase in bright red bleeding and clot formation

Question 328

A nurse is caring for a patient with functional incontinence. Which intervention would be most helpful? A) Bladder training and pelvic muscle exercises B) Scheduled toileting with assistive devices C) Limit fluid intake to reduce urine output D) Encourage frequent use of adult incontinence pads

Answer 328

B) Scheduled toileting with assistive devices

Question 329

Which dietary modification should the nurse suggest to a patient with diverticulosis to prevent complications? A) High-fiber diet with whole grains and vegetables B) Low-protein diet to reduce stool volume C) High-fat diet to prevent bowel irritability D) Low-fiber diet to avoid irritation of the colon

Answer 329

A) High-fiber diet with whole grains and vegetables

Question 330

A nurse is educating a patient with chronic constipation and diverticulosis. Which of the following should be avoided during the acute phase of diverticulitis? A) Laxatives and enemas B) A high-fiber diet C) A clear liquid diet D) Oral analgesics

Answer 330

A) Laxatives and enemas

Question 331

A nurse is caring for a patient with chronic diverticulosis. Which of the following interventions is most appropriate for prevention? A) Administer broad-spectrum antibiotics B) Encourage a high-fiber diet and adequate hydration C) Limit activity and avoid straining D) Teach the patient to restrict fluid intake

Answer 331

B) Encourage a high-fiber diet and adequate hydration

Question 332

A patient is being discharged after a TURP procedure. The nurse instructs the patient to report which of the following symptoms immediately? A) Bright red blood in the urine B) Difficulty voiding after catheter removal C) Mild pain during urination D) Feeling of urgency to urinate

Answer 332

A) Bright red blood in the urine

Question 333

A patient with a history of stroke is experiencing functional incontinence. Which intervention should the nurse prioritize? A) Bladder training and pelvic floor exercises B) Scheduled toileting and the use of absorbent pads C) Administer anticholinergic medications D) Increase fluid intake to dilute urine

Answer 333

B) Scheduled toileting and the use of absorbent pads

Question 334

A patient with diverticulitis presents with fever, nausea, and a positive stool occult blood test. Which of the following actions should the nurse take first? A) Administer an opioid analgesic for pain relief B) Notify the healthcare provider for further evaluation C) Provide a high-fiber diet to promote healing D) Encourage fluid intake to prevent dehydration

Answer 334

B) Notify the healthcare provider for further evaluation

Question 335

A nurse is caring for a patient post-TURP who is at risk for hemorrhage. Which of the following is an important nursing intervention? A) Encourage deep breathing and coughing exercises B) Monitor the color and consistency of urine C) Promote high fluid intake and frequent urination D) Encourage the patient to ambulate frequently

Answer 335

B) Monitor the color and consistency of urine

Question 336

A patient undergoing treatment for diverticulitis is advised to avoid which of the following during the acute phase? A) Clear liquids B) High-fiber foods C) High-protein meals D) Foods containing seeds or nuts

Answer 336

D) Foods containing seeds or nuts