MISC
During rescue breathing in cardiopulmonary resuscitation (CPR), how will the nurse evaluate if the client is exhaling?
a. by providing gentle pressure to the upper chest
b. observe for normal relaxation of the chest
c. noting the depth of compressions at 2"
d. turning the client's head to the side
b. observe for normal relaxation of the chest
A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect?
a. S4 heart sound
b. Petechiae
C. Crackles in lung bases
D. Splenomegaly
C. Crackles in lung bases
The nurse is caring for a client who is to receive a blood transfusion. Which of the following would be anticipated nursing actions when administering a transfusion?
a. Administer the blood within 2 hours after receiving it from the blood bank
b. Monitor the client carefully for 1 hour to ensure no transfusion reaction occurs
c. Ensure the total time to transfuse the blood does not exceed 4 hours
d. Change the blood tubing after every 4 units to decrease the chance of contamination
c. Ensure the total time to transfuse the blood does not exceed 4 hours
A client has a platelet count of 18,000/mm3. What intervention must the nurse include in the plan of care?
a. Institute bleeding precautions
b. Institute neutropenic precautions
c. Schedule medications by IM route when able
d. Obtain temperatures rectally.
a. Institute bleeding precautions
A client with HF is taking digoxin and furosemide. A new diagnosis of acute bronchitis is made, and albuterol via inhalation is started. The nurse should anticipate that this client is at risk for what complication?
a. Hyperkalemia
b. Hypernatremia
c. Hypocalcemia
d. Hypokalemia
d. Hypokalemia
The nurse is caring for a client who is scheduled for a contrast study. The clients pre-procedure labs show a creatinine of 2.3 mmg/dL. While the administration of N-acetylcysteine and sodium bicarbonate is ordered, which of the following is considered the most effective way to prevent contrast related nephropathy?
a. Stop all antihypertensive medications before the procedure
b. Remove all vitamin K foods from the menu for 1 week
c. Prehydrate the client with a normal saline infusion
d. Ensure the blood pressure and O2 sat are adequate
c. Prehydrate the client with a normal saline infusion
A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect?
a. Petechiae
b. Murmur
c. Friction rub
d. Rash
c. Friction rub
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4 F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first?
a. Request arterial blood gases STAT.
b. Start an IV with an 18-gauge angiocath.
c. Prepare to administer analgesics as ordered.
d. Administer oxygen via nasal cannula.
d. Administer oxygen via nasal cannula.
A 74-year-old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure?
a. BNP 820
b. K + 5.6
c. BUN 9
d. Troponin <0.02
a. BNP 820
A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client?
a. 1 medium beef hot dog
b. 2 oz lean baked ham
c. 3oz fried chicken breast
d. 1 slice cheddar cheese
d. 1 slice cheddar cheese
The nurse is caring for a client that has just suffered a severe spinal cord injury that has left him paralyzed from the neck down. The family voices their concerns that the client will never be able to cope with his situation. How should the nurse best attempt to meet the client’s needs based on the concept of coping?
a. Coping is a physiologic measure used to deal with change, and he will physical adapt
b. Coping is a human need for faith and hope, both of which create change.
c. Coping is composed of the physiologic and psychological processes that people use to adapt to change.
d. Coping is a social strategy that is used to deal with change and loss.
c. Coping is composed of the physiologic and psychological processes that people use to adapt to change.
A nurse is caring for a 72-year old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of the procedure. Which of the following responses should the nurse give?
a. "This will improve blood flow in your mother's coronary arteries."
b. "This will permit your mother to resume her activities of daily living."
c. "This will prolong your mother's life."
d. "This will reverse the effects to the damaged area."
b. "This will permit your mother to resume her activities of daily living."
A nursing student is participating in the care of a patient with venous insufficiency. The patient's leg has 2+ pitting edema. Which intervention should the student perform for this patient?
a. Assist patient to dangle the leg
b. Assist patient to raise the leg on two pillows
c. Encourage the patient to stand for longer periods
d. Place the patient in a semifowler position
b. Assist patient to raise the leg on two pillows
Which lab tests assist in confirmation of the diagnosis of rheumatic endocarditis?
a. Throat culture
b. Arterial blood gas
c. Serum albumin
d. Liver enzymes
a. Throat culture
A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications?
a. Propranolol
b. Metoclopramide
c. Ranitidine
d. Vasopressin
c. Ranitidine
The nurse is with a patient who has learned that she has stage 4 breast cancer with an exceptionally poor prognosis. Her heart rate increases, eyes dilate, and blood pressure increases. The nurse recognizes these changes as being attributable to what response?
a. Part of the limbic system response.
b. Sympathetic nervous response.
c. Hypothalamic-pituitary response.
d. Local adaptation syndrome.
b. Sympathetic nervous response.
A client with endocarditis develops sudden leg pain with pallor, tingling, and a loss of peripheral pulses. What should be the nurse's initial action?
a. Elevate the leg above the level of the heart.
b. Wrap the leg in a loose blanket.
c. Notify the healthcare provider about the findings.
d. Perform passive ROM exercise to stimulate circulation.
b. Wrap the leg in a loose blanket.
The client is exhibiting symptoms of acute arterial occlusion. Without immediate intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg to maintain warmth and protect it from further injury.
The nurse is teaching a client with hemophilia A about home management. Which strategy should the nurse include in the teaching plan?
a. Increase iron rich foods in the diet
b. avoid contact sports
c. Use aspirin when severe pain occurs
d. Minimize joint pain by walking and weight bearing
b. avoid contact sports
Which lab test would indicate an exacerbation of Crohn's disease?
a. Hematocrit
b. Erythrocyte sedimentation rate
c. elevated WBC
d. Albumin
b. Erythrocyte sedimentation rate
The nurse is removing a client's femoral sheath after cardiac catheterization. What medication will the nurse have available?
a. Heparin
b. Protamine sulfate
c. Atropine sulfate
d. Adenosine
c. Atropine sulfate
A nurse is providing teaching to the parent of a child who has contact dermatitis. Which of the following information should the nurse include?
a. Use fabric softener dryer sheets when drying clothing
b. Apply a warm, dry compress to the rash area
c. Leave hands uncovered during the night
d. Place in a bath with colloidal oatmeal
d. Place in a bath with colloidal oatmeal
A client's angiogram demonstrates the final stage of atherosclerosis. The nurse concludes that this client's pathophysiology includes which late developing element?
a. Presence of atheromas
b. Fatty deposits in the intima
c. Lipoprotein accumulation in the intima
d. Inflammation of the arterial wall
a. Presence of atheromas
When working with a client with peripheral areterial disease, the nurse assesses for which signs and symptoms that would be consistent with tissue ischemia? Select all that apply.
a. Peripheral edema
b. Thickened toenails
c. Leg pain while walking
d. Brownish discoloration to the skin on the leg
e. Cooler skin temperature on affected extremity
b. Thickened toenails
c. Leg pain while walking
e. Cooler skin temperature on affected extremity
A client with thrombocytopenia presents to the primary care center. During assessment, the nurse notices petechiae. The nurse interprets that which laboratory result best supports the presence of a disorder of hemostasis?
a. decreased erythrocyte count
b. a platelet count below 150,000/mm3
c. An elevated lymphocyte count
d. a hemoglobin value of 14 or more
b. a platelet count below 150,000/mm3
The nurse determines that a hypertensive client understands the DASH diet when the client chooses which items from a sample menu used in dietary teaching?
a. Caesar salad, read sticks, frozen yogurt
b. Grilled chicken sandwich, strawberries, and lettuce salad.
c. Grilled cheese sandwich, canned pineapple, brownie
d. Chicken and vegetable stir-fry, rice, egg roll
b. Grilled chicken sandwich, strawberries, and lettuce salad.