Health Alterations 2

Heart Failure

100

A client with a diagnosis of heart failure asks how to limit fluid intake to 2,000 mL/day. The nurse's best response would be: a) "This is the same as a 2 L bottle of soda. Pour the amount of fluid you drink into an empty soda bottle to keep track of how much you drink." b) "Each glass contains 8 oz. There are 30 mL per ounce, so you can have a total of 8 glasses or cups of fluid each day." c) "This is the same as 2 quarts or about the same as two pots of coffee." d) "Just take sips of water or ice chips. That way you will not take in too much fluid."

a) "This is the same as a 2 L bottle of soda. Pour the amount of fluid you drink into an empty soda bottle to keep track of how much you drink."

200

A client with a diagnosis of heart failure reports not taking diuretics on days that activities are scheduled to prevent having to go to the bathroom all the time. Which of the following statements by the nurse assesses the effect of this action? a) "Do you take the medication later in the day when you return home?" b) "Do you have more difficulty breathing or swelling in your legs the next day?" c) "You should take the medicine earlier so its effect is gone before the activity begins." d) "That is why you had to be admitted to the hospital again to remove excess fluid."

b) "Do you have more difficulty breathing or swelling in your legs the next day?"

300

Which of these findings is suggestive of a diagnosis of right-sided heart failure? a) cyanosis b) wheezing c) productive cough d) jugular vein distension

D) jugular vein distension

400

For a client admitted with a diagnosis of left-sided heart failure, the nurse should closely monitor for the development of which of these clinical manifestations? (select all that apply): a) rales b) jaundice c) wheezing d) arm and leg pruritis e) 1-2 pillow dyspnea

a) rales c) wheezing e) 1-2 pillow dyspnea

500

When providing discharge instructions for a client taking furosemide (Lasix) and a potassium for the treatment of heart failure, the nurse should include which instruction when teaching about the side effects of these medications? a) Avoid making sudden position changes. b) Drink at least one glass of water per day. c) To prevent leg cramps, eat canned vegetables. d) Completely dissolve potassium supplements in mike before taking.

a) Avoid making sudden position changes.

Peripheral Vascular

100

A nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a client with peripheral arterial disease. Following client teaching, the nurse determines a need for further instruction when the client says, a) "I will wear loose clothing that does not bind across my legs or waist." b) "I will change positions every hour, avoid sitting with my legs crossed, and avoid long periods of sitting with my legs down." c) "I will sleep with a heating pad on my feet at night to increase the circulation and warmth in my feet." d) "For 30 min. to an hour each day, I will walk to the point of pain, rest, and then walk again until I develop pain."

c) "I will sleep with a heating pad on my feet at night to increase the circulation and warmth in my feet."

200

Which assessment data would support the diagnosis of abdominal aortic aneurysm (AAA)? a) Shortness of breath b) Abdominal bruit c) Ripping abdominal pain d) Decreased urinary output

b) Abdominal bruit

300

In assessing a diabetic client with chronic arterial insufficiency, the nurse should anticipate which of these vascular changes? a) a negative Homan's sign b) strong, bounding pedal pulses c) edema affecting the entire leg d) diminished or absent pedal pulses

d) diminished or absent pedal pulses

400

In conducting a health history it is important for the nurse to include which of these questions for a client with intermittent claudication? a) "Do you have leg pain when you walk?" b) "Have you ever worn supportive stockings?" c) "What types of food do you usually eat?" d) "Describe your activities during a usual day."

a) "Do you have leg pain when you walk?"

500

Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon? a) Explain exacerbations will not occur in the summer b) Use nicotine gum to help quit smoking c) Wear extra warm clothing during cold exposure d) Avoid prolonged exposure to direct sunlight

c) Wear extra warm clothing during cold exposure

Upper Respiratory

100

Which nursing diagnosis is MOST appropriate for a client being treated for sinusitis? a) pain b) anxiety c) impaired skin integrity d) altered nutrition: less than body requirements

a) pain

200

The primary goal of care for a client with epitaxis is to: a) reduce anxiety. b) ambulate unassisted. c) ensure a patent airway. d) verbalize preventative measure.

c) ensure a patent airway.

300

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem, "altered communication". Which intervention should the nurse implement? a) Instruct the client to drink a mixture of brandy and honey several ties a day b) Encourage the client to whisper instead of trying to speak at a normal level c) Provide the client with a blank note pad for writing any communication d) Explain that the client's aphoria may be become a persistent condition

c) Provide the client with a blank note pad for writing any communication

400

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? a) "These pills will make me feel better fast and I can return to work." b) "The antibiotics will help prevent me from developing a bacterial pneumonia." c) "If I had gotten this prescription sooner I could have prevented this illness." d) "I need to take these pills until I feel better, then I can stop taking the rest."

b) "The antibiotics will help prevent me from developing a bacterial pneumonia."

500

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? a) Elderly and chronically ill clients b) Child-care workers and children younger than age four years c) Hospital chaplains and health-care workers d) Schoolteachers and students living in a dormitory.

a) Elderly and chronically ill clients

Lower Respiratory

100

Which of these definitions is accurate in describing pneumonia? a) inflammation of the bronchi b) inflammation of the upper airway c) inflammation of the bronchioles and alveoli d) inflammation of the nasopharynx and larynx

c) inflammation of the bronchioles and alveoli

200

Which of these assessment findings is characteristic of a client experiencing asthma? (select all that apply): a) Normal breath sounds b) Prolonged expirations c) Purpura and petechaiie d) Audible chest wheezing e) Dry skin and pink nail beds

b) Prolonged exiprations d) Audible chest wheezing

300

On auscultation of the chest, which of these findings is indicative of a left pneumothorax? a) bilateral rales b) inspiratory crackles to the left chest c) expiratory wheezes to the left chest d) absent breath sounds to the left chest

d) absent breath sounds to the left chest

400

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indicates the need for radiological evaluation instead of skin testing? a) The client's first skin test indicates a purple flat area at the site of injection b) The clients second skin test indicates a red area measuring 4 mm c) The client's previous skin test was read as positive d) The client has never shown a reaction to the tuberculin testing

c) The client's previous skin test was read as positive

500

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? a) Administer the oral antibiotic stat b) Order the meal tray to be delivered as soon as possible c) Obtain a sputum specimen for culture and sensitivity d) Have the unlicensed nursing assistant weigh the client

c) Obtain a sputum specimen for culture and sensitivity

COPD

100

In assessing the client with emphysema, the nurse should anticipate which of these physical findings? a) aphasia b) a barrel chest c) arm and leg weakness d) absence of a gag reflex

a) a barrel chest

200

Which of these client populations is MOST at risk for developing chronic obstructive pulmonary lung conditions? a) diabetics b) cigarette smokers c) food-service workers d) nursing home residents

b) cigarette smokers

300

The nurse is caring for the client diagnosed with end-stage COPD. Which data would warrant immediate intervention by the nurse? a) The client's pulse oximeter reading is 92% b) The client's arterial blood gas level is 74 c) The client has SOB when walking to the bathroom d) The client's sputum is rusty colored

d) The client's sputum is rusty colored

400

What statement made by the client diagnosed with chronic bronchitis indicates to the nurse that more teaching is needed? a) "I should contact my health-care provider if my sputum changes color or amount." b) "I will take my bronchodilator regularly to prevent having bronchospasms." c) "This metered dose inhaler gives a precise amount of medications with each dose." d) "I need to return to the HCP to have my blood drawn with my annual physical."

d) "I need to return to the HCP to have my blood drawn with my annual physical."

500

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? a) Assist the client into a sitting position at 90 degrees b) Give oxygen at six liters per minute via nasal cannula c) Monitor vital signs with the client sitting upright d) Notify the health-care provider about the client's status

a) Assist the client into a sitting position at 90 degrees