Cardio
A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?
A. Apples
B. Cheese
C. Oranges
D. Skim milk
B. Cheese
Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client?
A. Stridor and cyanotic lips
B. Diminished breath sounds and fever
C. Wheezes and use of accessory muscles
D. Pleural friction rub and inspirational chest pain
C. Wheezes and use of accessory muscles
Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.
The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?
A. Speaking to the client at a slower rate
B. Allowing plenty of time for the client to respond
C. Completing the sentences that the client cannot finish
D. Looking directly at the client during attempts at speech
C. Completing the sentences that the client cannot finish
Clients with aphasia after stroke often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing impatient for a response, and completing responses for the client.
The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching?
A. The nursing student tells the client to avoid soaking the feet.
B. The nursing student dries the feet thoroughly, including in between the toes.
C. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming.
D. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
D. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some client’s may not be able to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client’s feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming, a podiatrist or a physician’s order may be necessary to trim the nails, as a client with diabetes mellitus is at increased risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention given to the areas in between the toes, as skin breakdown or ulcers can go undetected in this area. Lotion needs to be applied to the dorsal and plantar surfaces of the foot. However, it would not be applied in between the toes as this area needs to be kept dry. Therefore, option 4 is the action by the nursing student that requires a need for further teaching.
A patient with a pressure ulcer on the sacrum has been prescribed a hydrocolloid dressing. The nurse knows that this type of dressing is used for which purpose?]
A. Debride necrotic tissue
B. Absorb heavy exudate
C. Maintain a moist wound environment
D. Deliver topical antibiotics
C. Maintain a moist wound environment
Hydrocolloid dressings are used to maintain a moist wound environment, which promotes healing. They are not typically used for debridement, absorbing heavy exudate, or delivering topical antibiotics. Hydrocolloid dressings are most effective for wounds with low to moderate exudate.
A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?
A. 3.2 mEq/L (3.2 mmol/L)
B. 3.8 mEq/L (3.8 mmol/L)
C. 4.2 mEq/L (4.2 mmol/L)
D. 4.8 mEq/L (4.8 mmol/L)
A. 3.2 mEq/L (3.2 mmol/L)
The normal serum potassium level in the adult is 3.5 mEq/L to 5.0 mEq/L (3.5–5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.
The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)?
A. Pedal pulses 2+
B. Tracheal deviation to the left
C. Capillary refill time of 2 seconds
D. Ecchymosis noted on the chest and abdomen
B. Tracheal deviation to the left
A tension pneumothorax is a life-threatening emergency that results when air enters the pleural space but cannot escape. The intrapleural pressures increasingly elevate, which results in compression of the lung on the affected side and pressure on the heart and great vessels, which decreases cardiac output. The mediastinum also shifts toward the unaffected side, which further compromises oxygenation by compressing the unaffected lung. The trachea deviates towards the unaffected side. Option 2 is an abnormal assessment finding that indicates the client is suffering from a tension pneumothorax and needs to be immediately reported to the registered nurse, who will then notify the primary health care provider. Options 1 and 3 are normal assessment findings. Option 4 is an expected assessment finding for a client who suffered blunt trauma to those areas and is not the priority over option 2.
The nurse observes the assistive personnel (AP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?
A. Head midline
B. Head turned to the side
C. Neck in neutral position
D. Head of bed elevated 30 to 45 degrees
B. Head turned to the side
The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia
D. Preventing and recognizing hyperglycemia
The normal reference range for the glycosylated hemoglobin A1c (HgbA1c) is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Therefore, an HgbA1c of 9% is elevated. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.
A patient presents with a large, irregularly shaped, dark brown mole with uneven borders on the back. The nurse should suspect which condition?
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Malignant melanoma
D. Actinic keratosis
C. Malignant melanoma
Malignant melanoma often presents as a large, irregularly shaped mole with uneven borders and varying shades of color. Basal cell carcinoma usually appears as a pearly or waxy bump. Squamous cell carcinoma often looks like a firm, red nodule or a flat lesion with a scaly, crusted surface. Actinic keratosis is a rough, scaly patch on the skin caused by sun damage.
A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?
A. Monitor for kidney failure.
B. Monitor psychosocial status.
C. Monitor for signs of bleeding.
D. Have heparin sodium available.
C. Monitor for signs of bleeding.
Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse would monitor the client for which acid–base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
C. Respiratory acidosis
Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD.
A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first?
A. Document the findings.
B. Attempt to arouse the client.
C. Contact the registered nurse immediately.
D. Check the medication administration history on the PCA pump.
B. Attempt to arouse the client.
The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should notify the registered nurse as the next step after attempting to arouse the client. The nurse would also then document the findings after all data is collected, the client is stabilized, and if an abnormality still exists after arousing the client.
The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason?
A. Treat thyroid storm.
B. Prevent cardiac irritability.
C. Treat hypocalcemic tetany.
D. Stimulate the release of parathyroid hormone.
C. Treat hypocalcemic tetany.
Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.
A nurse is providing care for a patient with cellulitis. Which of the following interventions should the nurse include in the care plan?
A. Apply ice packs to the affected area
B. Elevate the affected extremity
C. Keep the affected area exposed to air
D. Perform range of motion exercises
B. Elevate the affected extremity
Elevating the affected extremity helps reduce swelling and promote venous return in patients with cellulitis. Applying ice packs is generally not recommended, as it can restrict blood flow. The affected area should be kept clean and covered, not exposed to air. Range of motion exercises are not indicated during the acute phase of cellulitis.
The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention would the nurse do first?
A. Go to the nurse's station quickly and call a code.
B. Run to get a defibrillator from an adjacent nursing unit.
C. Call for help and initiate cardiopulmonary resuscitation (CPR).
D. Start oxygen by cannula at 10 L/minute and lower the head of the bed.
C. Call for help and initiate cardiopulmonary resuscitation (CPR).
When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 1, 2, and 4 are incorrect.
The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?
A. Continue to monitor.
B. Empty the drainage.
C. Encourage the client to deep breathe.
D. Encourage the client to hold his or her breath periodically.
A. Continue to monitor.
The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her (client) breath.
A client with a seizure disorder is being admitted to the hospital. Which would the nurse plan to implement for this client? Select all that apply.
A. Pad the bed's side rails.
B. Place an airway at the bedside.
C. Place oxygen equipment at the bedside.
D. Place suction equipment at the bedside.
E. Tape a padded tongue blade to the wall at the head of the bed.
A. Pad the bed's side rails.
B. Place an airway at the bedside.
C. Place oxygen equipment at the bedside.
D. Place suction equipment at the bedside.
The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway (to maintain airway patency if required) and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore, a padded tongue blade is not placed at the bedside.
A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information would the nurse reinforce upon discharge?
A. Keep insulin vials refrigerated at all times.
B. Rotate the insulin injection sites systematically.
C. Increase the amount of insulin before unusual exercise.
D. Monitor the urine acetone level to determine the insulin dosage.
B. Rotate the insulin injection sites systematically.
Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.
A patient is diagnosed with herpes zoster (shingles). Which of the following medications should the nurse anticipate administering?
A. Acyclovir
B. Amoxicillin
C. Loratadine
D. Hydrocortisone
Answer: A. Acyclovir
Rationale: Acyclovir is an antiviral medication used to treat herpes zoster (shingles). Amoxicillin is an antibiotic and is not effective against viral infections. Loratadine is an antihistamine used for allergies, and hydrocortisone is a corticosteroid used for inflammation but not specifically for herpes zoster.
A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions would the nurse take? Select all that apply.
A. Call a code blue.
B. Contact the client's family.
C. Check the client's pain level.
D. Check the client's blood pressure.
E. Administer a second nitroglycerin, 0.4 mg, sublingually.
C. Check the client's pain level.
D. Check the client's blood pressure.
E. Administer a second nitroglycerin, 0.4 mg, sublingually.
The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes as needed (PRN) for chest pain for a total dose of 3 tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.
A. Notify the RN.
B. Notify the Rapid Response Team.
C. Finish the suctioning as quickly as possible.
D. Discontinue suctioning until the client is stabilized.
E. Contact the respiratory department to suction the client.
A. Notify the RN.
D. Discontinue suctioning until the client is stabilized.
When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.
The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings would the nurse expect to observe because of meningeal irritation? Select all that apply.
A. Pupils are unequal and react slowly to light.
B. The client reports stiffness and soreness in the neck area.
C. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion.
D. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.
E. The client's upper arms are flexed and held tightly to the sides of the body, and the legs are extended and internally rotated.
B. The client reports stiffness and soreness in the neck area.
C. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion.
D. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.
Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses, or fungi. The client with meningitis experiences discomfort when pressure is placed on certain areas that irritate the inflamed meninges. Neck stiffness (nuchal rigidity) is an early sign of meningitis. A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner, and the client reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Unequal pupils and slowed pupillary response to light is a sign of increased intracranial pressure. This may occur in clients who are critically ill, but it is not a sign of meningeal irritation. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. This posturing occurs with severe brain damage, and the client requires emergency medical attention.
A nurse is planning care for a patient with hypothyroidism. Which of the following interventions should be included in the care plan? (Select all that apply)
A. Encourage a high-fiber diet.
B. Monitor for signs of hyperthyroidism.
C. Provide a warm environment.
D. Administer levothyroxine as prescribed.
E. Advise the patient to avoid sedatives.
A. Encourage a high-fiber diet.,
C. Provide a warm environment.,
D. Administer levothyroxine as prescribed.,
E. Advise the patient to avoid sedatives.
Hypothyroidism often leads to constipation, so a high-fiber diet is recommended. Patients are usually sensitive to cold, so providing a warm environment is beneficial. Levothyroxine is the standard treatment for hypothyroidism. Patients should avoid sedatives because hypothyroidism can already cause decreased metabolism and sedation, and additional sedatives may exacerbate this effect. Monitoring for signs of hyperthyroidism is also important, especially after starting levothyroxine therapy, but since the patient is currently hypothyroid, this is a secondary concern compared to the other interventions.
A nurse is caring for a patient with second-degree burns over 30% of their body. Which of the following interventions should be included in the immediate care plan? (Select all that apply)
A. Administer intravenous fluids
B. Apply antibiotic ointment to the burns
C. Cover the burns with a clean, dry cloth
D. Provide high-protein, high-calorie nutrition
E. Administer tetanus prophylaxis
Answers: A. Administer intravenous fluids, B. Apply antibiotic ointment to the burns, C. Cover the burns with a clean, dry cloth, E. Administer tetanus prophylaxis
Rationale: Immediate care for second-degree burns involves administering intravenous fluids to prevent shock and maintain hydration, applying antibiotic ointment to prevent infection, and covering burns with a clean, dry cloth to protect the wound. Tetanus prophylaxis is important as burns are prone to infection. High-protein, high-calorie nutrition is crucial for recovery but is not part of the immediate care in the acute phase.