Pulmonary embolism
A pt develops a pulmonary embolism. which assessment findings should the nurse recognize as possible manifestation of PE?
a. Dyspnea
b. Tachycardia
c. Bradycardia
d. pleuritic chest pain
e. hemoptysis
f. diaphorisis
what is....
A,B,D,E,F
A nurse cares for a client with end-stage cirrhosis who presents with confusion, asterixis, and elevated serum ammonia levels. Which medication should the nurse plan to administer to address these symptoms?
what is Lactulose
Rationale: Lactulose trapping ammonia in the gut encourages its excretion through frequent bowel movements, lowering serum ammonia levels in hepatic encephalopathy.
A nurse is conducting a health screening at a community clinic. Which client is at the highest risk for contracting Hepatitis E?
A. A paramedic who sustained an accidental blood splash on intact skin.
B. An individual receiving blood transfusions in 1985.
C. A traveler returning from an international destination with poor sanitation where they consumed local water.
D. A healthcare client with a history of long-term intravenous drug use.
what is ......
C. A traveler returning from an international destination with poor sanitation where they consumed local water.
Rationale: Hepatitis E, like Hepatitis A, is transmitted via the fecal-oral route, particularly through contaminated water in regions with poor sanitation.
This level of anxiety is characterized by a severely reduced perceptual field, prominent physical somatic symptoms, and a greatly reduced ability to problem-solve or think clearly.
The nurse is preparing to administer digoxin to a patient with heart failure. Which finding requires the nurse to withhold the medication and notify the prescriber?
A. Serum potassium level of 4.2 mEq/L
B. Apical heart rate of 76 beats/min
C. Apical heart rate of 56 beats/min
D. Blood pressure of 128/74 mm Hg
what is ....
C. Digoxin should be withheld when the heart rate is less than 60 beats/min because the medication decreases heart rate and AV-node conduction. The prescriber should be notified.
A patient with a suspected massive PE suddenly develops severe dyspnea, cyanosis, and hypotension. What is the nurse's priority?
A. Reduce the patient's anxiety.
B. Encourage ambulation.
C. Address oxygenation and hemodynamic instability.
D. Apply compression stockings.
WHAT IS ....
C.Address oxygenation and hemodynamic instability.
A client with decompensated cirrhosis is scheduled for a large-volume therapeutic paracentesis. Which action is essential for the nurse to perform immediately before the procedure?
what is.... instruct the client to void completely.
Rationale: Emptying the bladder immediately before paracentesis prevents accidental bladder perforating during needle insertion into the lower abdomen.
A nurse is assessing a client presenting with malaise, dark urine, clay-colored stools, and jaundice. Laboratory testing reveals elevated liver enzymes and positive IgM anti-HAV antibodies.Which question is most important for the nurse to ask during the health history evaluation?
A. "Have you received a blood transfusion prior to 1992?"
B. "Have you recently traveled internationally or consumed potentially contaminated food or water?"
C. "Do you have a history of sharing intravenous drug needles?"
D. "Have you ever been diagnosed with Hepatitis B?"
what is...
b. Have you recently traveled internationally or consumed potentially contaminated food or water?
Rationale: The presence of IgM anti-HAV confirms an acute Hepatitis A infection. Hepatitis A is transmitted via the fecal-oral route, commonly through contaminated food/water, poor sanitation, or travel to endemic areas.
This core feature distinguishes Generalized Anxiety Disorder (GAD) from Panic Disorder in clinical presentation.
A. Persistent, excessive worry across broad life domains lasting six months or longer.
B. Immediate autonomic fear triggered exclusively by exposure to a single object.
C. Marked fear of negative evaluation or scrutiny during public performance.
D. Recurrent, unexpected panic attacks accompanied by a fear of future attacks.
what is....
A. persistent, excessive worry across broad life domains lasting six months or longer
Rationale: GAD is characterized by pervasive, difficult- to-control worry across multiple areas of life lasting >or = 6 mo., whereas panic disorder features recurrent, sudden, unexpected panic surges.
The nurse is caring for a patient with mitral stenosis. Which findings should the nurse expect as the disorder progresses? Select all that apply.
A. A rumbling apical diastolic murmur
B. Palpitations associated with atrial fibrillation
C. Orthopnea and paroxysmal nocturnal dyspnea
D. Dyspnea on exertion
E. Improved pulmonary oxygenation with decreased pulmonary artery pressure
F. A crescendo-decrescendo systolic murmur radiating to the neck
what is.....
A,B,C,D
The nurse receives report on four patients. Which patient should the nurse assess first?
A. Patient with PE who reports anxiety
B. Patient with PE who has a low-grade fever
C. Patient with PE who has tachycardia and tachypnea
D. Patient with PE who has hypotension and cyanosis
WHAT IS ...
D. patient with PE whois hypotensive and cyanotic
A client with advanced liver cirrhosis develops severe ascites. Which interventions should the nurse include in the plan of care?
HINT: 3 total answers...
what is......
a. Implement a strict dietary sodium restriction (2g/day)
b. Measure abdominal girth daily at the level of the umbilicus
c. position pt in semi-fowlers's position when in bed.
A patient diagnosed with chronic Hepatitis C is being evaluated for combination therapy consisting of pegylated Interferon and Ribavirin. Which baseline laboratory assessment is most critical prior to initiating Ribavirin?
Complete blood count, specifically hemoglobin and hematocrit
Rationale: Ribavirin causes severe hemolytic anemia, usually developing within the first 1-4 weeks of therapy. Baseline hemoglobin and hematocrit are essential to monitor for dangerous drops.
This client statement regarding a newly prescribed dose of buspirone indicates a need for
A. I need to take this medication regularly every day as prescribed.
B. I will take this medication only when I feel a panic attack starting.
C. It may take several weeks before I experience the full therapeutic benefit.
D. I should discuss all over-the-counter supplements with my healthcare provider.
further clinical teaching.
what is ....
B. I will take this medication only when i fell a panic attack starting
Rationale: Buspirone is scheduled, non-benzodiazepine anxiolytic requiring weeks of consistent daily administration to reach therapeutic effectiveness; it is ineffective as a PRN rescue drug
The nurse is caring for a patient immediately after transcatheter aortic valve replacement (TAVR). Which intervention should the nurse anticipate as part of the usual postprocedural care?
A. Encourage unrestricted ambulation immediately after the procedure.
B. Prepare the patient for routine open-heart valve replacement after every TAVR.
C. Discharge the patient directly from the procedure area without overnight monitoring.
D. Maintain bed rest for 6 hours and monitor the patient overnight for complications.
what is ...
D
A patient with a pulmonary embolism is receiving an unfractionated heparin infusion. Which laboratory result is most important for the nurse to monitor to evaluate the therapeutic effect?
what is....
aPTT
rationale: The aPTT is monitored before and during unfractionated heparin therapy; therapeutic values for pulmonary embolism are generally 1.5 to 2.5 times the control value.
A nurse receives report on four clients with end-stage liver disease. Which client should the nurse assess first?
a. A client with 3+ bilateral lower extremities pitting edema and abdominal distention
b. A client whose bilirubin is 4.8 mg/dL and reports severe generalized sclera icterus
c. A client who vomited 250 mL of bright red blood and has a bp of 88/54 mmHg
d. A client exhibiting flapping hand tremor when extending wrist
wat is....
C. A client who vomited 250 mL of bright red blood and has a bp of 88/54 mmHg
Rationale: Hematemesis with hypotension indicates acutely rupture esophageal varices and hypovolemic shock, requiring emergent stabilization.
The nurse is providing discharge instructions to a client with chronic Hepatitis C. Which statement made by the client indicates a need for further education?
a. I will get the Hepatitis A and Hepatitis B vaccines to prevent further liver damage.
B. I will refrain from sharing razors, toothbrushes, or nail clippers with family members.
C. Over-the-counter acetaminophen is completely safe as long as I do not exceed 4 grams per day.
D. I should avoid consuming any alcoholic beverages to protect my liver.
what is...
c. Over-the-counter acetaminophen is completely safe as long as I do not exceed 4 grams per day.
Rationale: This statement indicates a need for further teaching. Clients with chronic liver disease or hepatitis should avoid or severely restrict acetaminophen (often capped below 2 grams per day or completely restricted) due to increased risk of hepatotoxicity.
This cluster of clinical manifestations strongly suggests the onset of Serotonin Syndrome in a client taking sertraline.
Agitation, profuse diaphoresis, tachycardia, hyperreflexia, and muscle clonus.
rationale: serotonin syndrome presents with a triad of altered mental status, autonomic instability and neuromuscular hyperactivity.
Which assessment finding should the nurse expect in a patient with aortic regurgitation?
A. Bounding peripheral pulses and widened pulse pressure
B. Weak peripheral pulses and narrowed pulse pressure
C. A holosystolic murmur at the apex radiating to the left axilla
D. A low-pitched diastolic murmur with isolated right-sided heart failure
what is ...
A. Aortic regurgitation causes increased stroke volume and diastolic backflow, producing bounding pulses and a widened pulse pressure.
A patient with a massive pulmonary embolism develops shock and hemodynamic instability. Which therapies or interventions should the nurse anticipate? Select all that apply.
A.Discontinuation of all oxygen therapy
B.Vasoactive therapy if hypotension persists after fluid resuscitation
C.Pulmonary embolectomy if thrombolytic therapy is contraindicated
D.Continuous hemodynamic monitoring
E.Routine ambulation to prevent additional emboli
F.Fibrinolytic therapy with alteplase
what is
B. vasopressors such as norepinephrine, epinephrine, or dopamine may be used when hypotension persists despite fluid therapy.
C. Hemodynamically unstable patients with massive pulmonary embolism may be candidates for embolectomy when thrombolytic therapy cannot be used.
D. Patients with severe pulmonary embolism require close monitoring of blood pressure, cardiac rhythm, oxygenation, and other cardiopulmonary indicators because right-sided heart failure and shock can occur.
F. Alteplase may be used for pulmonary embolism when shock, hemodynamic collapse, or instability is present; close monitoring for bleeding is required.
The nurse is teaching a patient with chronic hepatitis C and compensated cirrhosis who is also living with stable HIV infection. Which statements should the nurse include in the teaching plan? Select all that apply.
A. Sharing toothbrushes with household members is safe because hepatitis C is spread by casual contact
B. Treatment for hepatitis C may be provided when HIV is stable and the CD4 count is greater than 200 per microliter
C. A positive anti-HCV result should be followed by HCV RNA testing to confirm active infection
D. Direct-acting antiviral therapy may eradicate hepatitis C in most patients who complete treatment
E. A hepatitis C vaccine will prevent reinfection after treatment
F. Regular liver cancer screening is needed because the patient has hepatitis C cirrhosis, even if the virus is later cleared
what is ...
B. Patients with stable HIV and CD4 counts greater than 200 per microliter can receive HCV treatment to eradicate the virus and reduce progression toward cirrhosis.
C. Anti-HCV antibodies may reflect a past infection; HCV RNA confirms circulating virus and can measure viral load.
D. Direct-acting antiviral therapy generally lasts 8 to 12 weeks, and more than 95% of patients who complete therapy achieve a cure.
F. Patients with hepatitis C cirrhosis require regular screening for liver cancer even after clearing the virus.
A patient with cirrhosis and ascites is receiving diuretic therapy. Which assessment finding requires the nurse's immediate follow-up?
A.A daily weight loss of 0.5 kg
B.Serum potassium level of 2.8 mEq/L
C.A decrease in abdominal girth by 2 cm
D.A reduction in dependent peripheral edema
what is...
B. Severe hypokalemia is a serious complication of diuretic therapy and can cause potentially dangerous cardiac and neuromuscular effects.
This treatment approach represents the gold-standard nursing intervention for helping a client overcome a specific phobia.
A. Continuous verbal reassurance that the feared object cannot cause actual harm.
B. Permanent modification of the client's daily schedule to avoid the feared trigger entirely.
C. Immediate, unannounced exposure to the feared object to force rapid desensitization.
D. Gradual, collaborative exposure to the feared stimulus paired with coping skills.
what is ....
D. Gradual, collaborative exposure to the feared stimulus paired with coping skills.
Rationale: Graduated exposure therapy helps the client build mastery and tolerance toward the feared object or situation while reducing avoidance behavior.
A patient with acute mitral regurgitation has thready peripheral pulses, cool clammy extremities, and signs of reduced cardiac output. Which action should the nurse anticipate as the priority?
A. Rapid cardiac assessment followed by urgent valve repair or replacement
B. Delay intervention until pulmonary hypertension develops
C. Routine monitoring because mitral regurgitation is usually asymptomatic for years
D. Observation until peripheral edema develops
what is ....
A. Acute mitral regurgitation can cause severe reduction in cardiac output. Rapid assessment, such as heart catheterization, and urgent valve repair or replacement are critical.