Cardiovascular System
What action is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?
1. Decrease anxiety
2. Enhance myocardial oxygenation
3. Administer sublingual nitroglycerin
4. Educate the client about his symptoms
2. Enhancing myocardial oxygenation is always the first priority when a client exhibits signs and symptoms of cardiac compromise
A client with anemia may be tired due to a tissue deficiency of which substance?
1. Carbon dioxide
2. Factor VIII
3. Oxygen
4. T-cell antibodies
3. Anemia stems from a decreased number of red blood cells and the resulting deficiency of oxygen in body tissues.
Which pathophysiological mechanism will be expected to develop as a secondary response to pneumonia after development of the primary causative organism?
1. Atelectasis
2. Bronchiectasis
3. Effusion
4. Inflammation
4. The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent
A client who had cataract surgery should be told to call his physician if which condition is present?
1. Blurred vision
2. Eye pain
3. Glare
4. Itching
2. Pain shouldn't be present after cataract surgery
A client has been prescribed a diet that limits purine-rich foods. Which food would the nurse teach her to avoid eating?
1. Bananas and dried fruits
2. Milk, ice cream, and yogurt
3. Wine, cheese, preserved fruits, meats, and vegetables
4. Anchovies, sardines, kidneys, sweetbreads, and lentils
4. Anchovies, sardines, kidneys, sweetbreads, and lentils are high in purines
Which landmark is the correct one for obtaining an apical pulse?
1. Left fifth intercostal space, midaxillary line
2. Left fifth intercostal space, midclavicular line
3.Left second intercostal space, midclavicular line
4. Left seventh intercostal space, midclavicular line
2. Left fifth intercostal space, midclavicular line
A nurse is caring for a client who has had a bone marrow transplant. Which nursing intervention has the highest priority?
1. Assisting the client with daily hygiene needs
2. Listening to the client's breath sounds every 2 hours to detect congestion
3. Palpating the client's pulses every 2 hours
4. Administering pain medication as necessary to promote rest and comfort
2. The major complications of bone marrow transplantation are bleeding and infection.
An elderly client with pneumonia has a nursing diagnosis of Ineffective airway clearance related to increased secretions and ineffective cough. Which intervention would facilitate effective coughing?
1. Lying in semi-Fowler position
2. Sipping water, hot tea, or coffee
3. Inhaling and exhaling from pursed lips
4. Using thoracic breathing
2. Sips of water, hot tea, or coffee may stimulate coughing
Clear fluid is draining from the nose of a client who had a head trauma 3 hours ago. This may indicate which condition?
1. Basilar skull fracture
2. Cerebral concussion
3. Cerebral palsy
4. Sinus infection
1. Clear fluid draining from the ear or nose of a client may mean cerebrospinal fluid leak, which is common in basilar skull fracture
A client is taking salicyates for osteoarthitis. The presence of which of the following indicates that further assessment is needed?
1. Hearing loss
2. Increased pain in joints
3. Decreased calcium absorption
4. Increased bone demineralization
1. Many elderly people already have diminished hearing, and salicyate use can lead to further or total hearing loss.
Which blood test is most indicative of cardiac damage?
1. Arterial blood gas (ABG) levels
2. Comnplete Blood Count (CBC)
3. Complete Chemistry
4. Creatine kinase isoenzymes (CK-MB)
4. CK-MB isoenzymes are present in the blood after a myocardial infarction
Which statement is an example of passive acquired immunity?
1. A child receives the necessary immunizations before beginning school
2. After having chicken pox, a teenager is unlikely to get the disease again
3. A nurse who is accidentally exposed to hepatitis B virus from a needle stick receives hepatitis B immune globulin
4. An adult develops shingles
3. Immune globulin provides temporary immunity that's passively acquired. Antibodies from one person are recovered and administered to another person to help prevent that person from being infected
The right forearm of a client who had purified protein derivative (PPD) test for tuberculosis (TB) is reddened and raised about 3mm where the test was given. This PPD would be read as having which result?
1. Indeterminate
2. Needs to be redone
3. Negative
4. Positive
3. This test would be classed as negative.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which nursing intervention is most appropriate to perform immediately?
1. Evaluate urine specific gravity
2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow the I.V. fluids and notify the physician
1. Urine output of 300 ml/hr may indicate diabetes insipidus, which is failure of the pituitary to produce antidiuretic hormone. This may occur with increased ICP and head trauma
A client uses a cane for assistance in walking. Which statement is true about a cane or other assistive device?
1. "A walker is a better choice than a cane"
2. "The cane should be used on the affected side"
3. "The cane should be used on the unaffected side"
4. "A client with osteoarthitis should be encouraged to ambulate without the cane"
3. A cane should be used on the unaffected side.
Which drug class causes dilation of the coronary arteries, decreases afterload, reduces cardiac contractility and slows the heart rate?
1. Positive inotropic agents
2. Nitrates
3. Beta-adrenergic blockers
4. Calcium channel blockers
4. Calcium channel blockers inhibit calcium influx through the coronary arteries, causing aterial dilation and decreasing peripheral vascular resistance, which reduces afterload.
A nurse is monitoring a 17-year-old male client who's receiving a blood transfusion for volume replacement. The client complains of itching about 20 minutes after the infusion begins. The nurse should:
1. Report the symptoms so that the infusion can be stopped immediately
2. Call the physician immediately
3. Give the client oral diphenhydramine (Benadryl) and continue to monitor the client's symptoms
4. Do nothing because itching is a normal response to a blood transfusion
1. itching is a sign of an adverse reaction, so the nurse must report the symptom immediately so that the infusion can be stopped
A client was infected with tuberculosis (TB) bacillus 10 years ago but never developed the disease. He's now being treated for cancer. The client begins to develop signs of TB. This is known as which type of infection?
1. Active infection
2. Primary infection
3. Superinfection
4. Tertiary infection
1. Some people carry dormant TB infections that may develop into active disease.
A client with a subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which result would best show the mannitol was effective?
1. Urine output increases
2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. Blood urea nitrogen (BUN) and creatinine levels return to normal
1. Mannitol promotes osmotic diureses by increasing the pressure gradient in the renal tubules.
Treatment of compartment syndrome includes which measure?
1. Amputation
2. Casting
3. Fasciotomy
4. Observation; no treatment is necessary
3. Treatment of compartment syndrome includes fasciotomy. A fasciotomy involves cutting the fascia over the affected area to permit muscle expansion
A client is admitted with sinus bradycardia, nausea, and anorexia, and reports blurred and yellow vision disturbances. Toxicity of which drug is most likely responsible for all of these symptoms?
1. Digoxin (Lanoxin)
2. Atenolol (Tenormin)
3. Benazepril (Lotensin)
4. Diltiazem (Cardizem)
1. Digoxin toxicity typically causes bradycardia, nausea, anorexia, and yellow vision disturbances.
According to a standard staging classification of Hodgkin disease, which criteria reflect stage II?
1. Involvement of extra lymphatic organs or tissues2. Involvement of a single lymph node region or structure
3. Involvement of two or more lymph node regions or structures
4. Involvement of lymph node regions or structures on both sides of the diaphragm
3. Stage II involves two or more lymph node regions
A client with emphysema should receive only enough supplemental oxygen to maintain his PaO2 at 60 mm Hg or higher, or he may lose his hypoxic drive. Which statement is correct about hypoxic drive?
1. The client doesn't notice he needs to breathe
2. The client breathes only when his oxygen levels climbs above a certain point
3. The client breathes only when his oxygen levels dip below a certain point
4. The client breathes only when his carbon dioxide level dips below a certain point
3. Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. Clients with emphysema and COPD take a breath when they've reached this low oxygen level. They don't take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology
A client is newly diagnosed with myasthenia gravis. Client teaching would include which condition as the cause of this disease?
1. A postviral illness characterized by ascending paralysis
2. Loss of the myelin sheeth surrouning peripheral nerves
3. Inability of basal ganglia to produce sufficient dopamine
4. Destruction of acetylcholine receptors, causing muscle weakness
4. Myasthenia gravis, an autoimmune disorder, is caused by the destruction of acetylcholine receptors.
If pulses aren't palpable, which intervention should be performed first?
1. Check again in 1 hour
2. Alert the nurse in charge immediately
3. Verify the findings with a handheld Doppler
4. Alert the physician immediately
3. If pulses aren't palpable, verify the observation with Doppler ultrasonography. If pulses can't be found with handheld Doppler, immediately notify physician