Exam 1

Question 1

Hyperventilation, with a resulting decrease in PaCO2, is an expected compensatory reaction to the acid–base disorder of ____________ acidosis.

Answer 1

metabolic

Question 2

T/F: Body fluid is located in two fluid compartments: the intracellular space (fluid in the cells) and the extracellular space (fluid outside the cells).

Answer 2

TRUE

Question 3

T/F: When monitoring a patient’s potassium level, the nurse is aware that tall, tented, “T” waves on an ECG are indicative of hypokalemia.

Answer 3

FALSE: Hypokalemia presents w/ ECG: flattened T waves, prominent U waves, ST depression, prolonged PR interval

Question 4

The major electrolytes in the extracellular fluid are ____________ and chloride.

Answer 4

sodium

Question 5

The cardinal feature of metabolic acidosis is a decrease in the serum bicarbonate level.

Answer 5

TRUE

Question 6

Factors that increase BUN include decreased renal function, GI bleeding, ________________, increased protein intake, fever, and sepsis.

Answer 6

dehydration

Question 7

T/F: Vital to the regulation of fluid and electrolyte balance, the kidneys normally filter 180 L of plasma every day in the adult and excrete 1 to 2 L of urine.

Answer 7

TRUE

Question 8

When monitoring daily body weights to assess fluid volume deficit, the nurse understands that a loss of 0.5 kg (1.1 lb) represents a fluid loss of approximately _________ mL.

Answer 8

500

Question 9

Hyperaldosteronism increases renal ___________________ wasting and can lead to severe potassium depletion.

Answer 9

potassium

Question 10

T/F: A nurse should assess a patient with hypervolemia for indicators of hypotension, bradypnea, and oliguria.

Answer 10

FALSE: Acute weight loss, ↓ skin turgor, oliguria, concentrated urine, capillary filling time prolonged, low CVP, ↓ BP, flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse, muscle cramps, sunken eyes, nausea, increased temperature; cool, clammy, pale skin

Question 11

T/F: Myocardial dysfunction occurs when irreversibly damaged heart muscle is replaced by adipose tissue.

Answer 11

FALSE

Question 12

Blood vessels commonly used to bypass occluded coronary arteries include the __________________ veins of the leg.

Answer 12

saphenous

Question 13

T/F: For a patient to be considered a candidate for a coronary artery bypass graft (CABG), the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if the affected artery is the left main coronary artery).

Answer 13

TRUE

Question 14

A ___________ provides structural support to a coronary artery following angioplasty to minimize the risk of vessel stenosis.

Answer 14

stent

Question 15

Angina pectoris is chest pain resulting from myocardial _________ of the heart muscle.

Answer 15

ischemia

Question 16

Management of an elevated ___________________ level focuses on weight reduction and increased physical activity.

Answer 16

triglyceride

Question 17

Hypertension also increases the work of the __________________ ventricle, which must pump harder to eject blood into the arteries.

Answer 17

left

Question 18

T/F: The most common cause of cardiovascular disease in the United States is atherosclerosis, an abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls.

Answer 18

TRUE

Question 19

T/F: Clopidogrel (Plavix) is commonly prescribed in addition to aspirin in patients at high risk for MI.

Answer 19

TRUE- blood thinner to prevent MI

Question 20

T/F: Beta-blockers, such as Lopressor and Toprol, are the standard treatment for angina pectoris.

Answer 20

FALSE

Nitrates

Question 21

A patient is receiving intravenous fluids (IVF) postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?

Answer 21

fluid volume excess

Question 22

When evaluating a client’s response to treatment of a fluid imbalance, the most important assessment would be:

Answer 22

trending of daily weights.

Question 23

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

Answer 23

“Increase fluids if your mouth feels dry”

Question 24

The patient that has fluid overload has been taking a diuretic for the past two days and now experiences changes. Which change indicates that the diuretic is effective?

Answer 24

Weight loss of six pounds

Question 25

An older woman is admitted to the medical unit with gastrointestinal bleeding (GIB). Clinical manifestations would include:

Answer 25

weight loss

Question 26

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is:

Answer 26

osmosis

Question 27

A patient is admitted with congestive heart failure (CHF). What would you expect to find during your admission assessment?

Answer 27

Increased blood pressure and crackles throughout the lungs

Question 28

Which patient is at risk for experiencing a fluid volume deficient (FVD)? The patient:

Answer 28

who has been vomiting and having diarrhea for 2 days with continuous nasogastric suction with an abdominal wound vac at intermittent suction

Question 29

The nurse obtains a blood pressure reading of 50/30. The patient is awake, alert, and talking calmly with his family. Which action should the nurse take?

Answer 29

Recheck the blood pressure. | What you are seeing in the pt doesn't match the monitor- double check

Question 30

A patient has received a new diagnosis of stable angina. The nurse determines the client needs further education when they make the following statement:

Answer 30

"When experiencing angina, cardiac tissue is viable for 60 minutes."

Question 31

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

Answer 31

The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

Question 32

A nurse enters a client's room to find the client short of breath, rubbing his left arm and complaining of nausea. Which assessment would be the priority?

Answer 32

Assess for dysrhythmia. | Use an ECG

Question 33

The nurse is preparing a male patient who experienced a myocardial infarction for discharge. The patient expresses concern about having sex with his wife when he returns home. Which response by the nurse would be most helpful in lessening the patient's fears?

Answer 33

"It is common for patients to worry about resuming sexual activities. Tell me about your concerns."

Question 34

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

Answer 34

The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

Question 35

A client comes to the emergency room complaining of chest pain that radiates down the left arm. The nurse prepares to draw a blood specimen to test for:

Answer 35

Cardiac Biomarkers - Troponin - CK- MB - Myoglobin

Question 36

A client is prescribed medication for angina. The priority long-term goal should be:

Answer 36

increased tolerance for daily activities.

Question 37

After the nurse has finished teaching a client about the use of sublingual nitroglycerin, which client statement indicates the teaching has been effective?

Answer 37

"I will call 911 if I still have pain after taking my nitroglycerin."

Question 38

A patient with angina is instructed to rest when having an episode of chest pain. What is the best explanation for how rest relieves the pain associated with angina?

Answer 38

A balance between myocardial cellular needs and demand is achieved.

Question 39

While caring for a client recovering from a myocardial infarction and stent placement, the monitor alarm sounds and the nurse notes ventricular fibrillation. What is your priority intervention?

Answer 39

Assess the client's level of consciousness | Basic life support is "are you okay" can't shock someone awake/ alert \

Question 40

A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a:

Answer 40

high LDL level. Explanation: LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.

Question 41

To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)?

Answer 41

60 minutes Explanation: The 60-minute interval is known as “door-to-balloon time” in which a PTCA can be performed on a client with a diagnosed MI. The 30-minute interval is known as “door-to-needle time” for the administration of thrombolytics after MI. The time frame of 9 days refers to the time until the onset of vasculitis after administration of streptokinase for thrombolysis in a client with an acute MI. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same client for acute MI.

Question 42

The nurse is caring for a client with Raynaud’s disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?

Answer 42

Avoid situations that contribute to ischemic episodes. Explanation: Teaching for clients with Raynaud’s disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

Question 43

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

Answer 43

``` Morphine sulfate (Morphine) Explanation: Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina–type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain. ```

Question 44

The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure?

Answer 44

a serum BUN of 70 mg/dL Explanation: These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.

Question 45

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

Answer 45

Blood pressure 84/52 mm Hg Explanation: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

Question 46

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality?

Answer 46

Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.

Question 47

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding?

Answer 47

"What color is your urine?" Explanation: The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine.

Question 48

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?

Answer 48

Relieved by rest and nitroglycerin Explanation: One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.

Question 49

A client with a family history of coronary artery disease reports experiencing chest pain and palpitations during and after morning jogs. What would reduce the client’s cardiac risk?

Answer 49

smoking cessation Explanation: The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight. Antioxidant supplements, such as those containing vitamin E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use.

Question 50

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?

Answer 50

Unstable Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Question 51

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?

Answer 51

Headache, hypotension, dizziness, and flushing. Explanation: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic that relieves pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.

Question 52

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?

Answer 52

ST elevation Explanation: The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

Question 53

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

Answer 53

Hyperlipidemia Obesity Tobacco use

Question 54

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?

Answer 54

Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin).

Question 55

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?

Answer 55

"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.

Question 56

After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse's initial action?

Answer 56

Apply manual pressure at the site of the insertion of the sheath. Explanation: The immediate nursing action would be to apply pressure to the femoral site. Reviewing blood studies will not stop the bleeding. The nurse cannot decrease anticoagulation therapy independently. If the bleeding does not stop, the health care provider needs to be notified.

Question 57

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse?

Answer 57

The nurse will ask the dietitian to talk with the client about modifying the diet.

Question 58

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication?

Answer 58

Atelectasis Explanation: Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

Question 59

Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery?

Answer 59

Inadequate tissue perfusion Explanation: The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority.

Question 60

A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse?

Answer 60

Central venous pressure reading of 1 Explanation: The central venous pressure (CVP) reading of 1 is low (2–6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse’s priority.

Question 61

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?

Answer 61

To decrease workload of the heart Explanation: Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

Question 62

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?

Answer 62

“Removing the patch at night prevents drug tolerance while keeping the benefits.” Explanation: Tolerance to antianginal effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while the client rests, there is less demand on the heart but not the primary reason for removing the patch.

Question 63

The nurse is administering oral metoprolol. Where are the receptor sites mainly located?

Answer 63

Heart Explanation: Metoprolol works at beta 1 -receptor sites. Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

Question 64

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent?

Answer 64

Clopidogrel Explanation: Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.

Question 65

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?

Answer 65

Inadequate fluid volume Explanation: Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.

Question 66

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication?

Answer 66

160–190 mg/dL Explanation: Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

Question 67

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin?

Answer 67

Clopidogrel Explanation: Clopidogrel or ticlopidine is given to clients who are allergic to aspirin or are given in addition to aspirin to clients who are at high risk for MI. Amlodipine, diltiazem, and felodipine are calcium channel blockers.

Question 68

Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

Answer 68

Monitor the site for bleeding or hematoma. Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.

Question 69

Which is a diagnostic marker for inflammation of vascular endothelium?

Answer 69

C-reactive protein (CRP) Explanation: CRP is a marker for inflammation of the vascular endothelium.

Question 70

The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain?

Answer 70

a lack of oxygen in the heart muscle cells Explanation: Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction.

Question 71

The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome?

Answer 71

pericardial friction rub Explanation: Post-pericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of post-pericardiotomy syndrome.

Question 72

The nurse is assessing a postoperative patient who had a percutaneous transluminal coronary angioplasty (PTCA). Which possible complications should the nurse monitor for? (Select all that apply.)

Answer 72

``` Abrupt closure of the artery Arterial dissection Coronary artery vasospasm Explanation: Complications that can occur during a PTCA procedure include coronary artery dissection, perforation, abrupt closure, or vasospasm. Additional complications include acute myocardial infarction, serious dysrhythmias (e.g., ventricular tachycardia), and cardiac arrest. Some of these complications may require emergency surgical treatment. Complications after the procedure may include abrupt closure of the coronary artery and a variety of vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion (Bhatty, Cooke, Shettey, et al., 2011). ```

Question 73

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme?

Answer 73

myocardial necrosis Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

Question 74

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse?

Answer 74

Altered level of consciousness Explanation: A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client’s chest pain is subsiding, an expected outcome of this therapy.

Question 75

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client?

Answer 75

enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.

Question 76

A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern?

Answer 76

hematocrit of 30% Explanation: Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding.

Question 77

The nurse is removing a client's femoral sheath after cardiac catheterization. What medication will the nurse have available?

Answer 77

atropine sulfate Explanation: Removing the sheath after cardiac catheterization may cause a vasovagal response, including bradycardia. The nurse should have atropine sulfate on hand to increase the client's heart rate if this occurs. Heparin changes clotting of blood; clients should stop taking it before the sheath removal. Protamine sulfate is an antidote to heparin, but the nurse shouldn't administer it during sheath removal. Adenosine treats tachydysrhythmias.

Question 78

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?

Answer 78

Withhold anticoagulant therapy. Explanation: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

Question 79

A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?

Answer 79

Coronary artery disease Explanation: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud’s disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.

Question 80

T/F: A patient with pulmonary edema should be positioned upright, preferably with the legs dangling over the side of the bed, if possible

Answer 80

TRUE

Question 81

The three major types or classifications of cardiomyopathy, a disease of the myocardium are as follows: dilated, hypertrophic and _______________.

Answer 81

restrictive

Question 82

T/F: Digitalis (digoxin) is considered the most essential and most frequently prescribed pharmacologic agent for the treatment of heart failure.

Answer 82

FALSE

Question 83

_____________ causes myocardial dysfunction in heart failure because it deprives heart cells of oxygen and causes cellular damage.

Answer 83

ischemia

Question 84

T/F: The most common type of heart failure is an alteration in ventricular contraction called diastolic heart failure, which is characterized by a weakened heart muscle.

Answer 84

FALSE

Question 85

Because HF is a complex and progressive condition, patients are at risk for many complications, including acute decompensated HF, ________________, kidney disease, and life-threatening dysrhythmias.

Answer 85

pulmonary edema

Question 86

Pulmonary edema can also develop slowly, especially when it is caused by _________________ disorders such as kidney disease and other conditions that cause fluid overload.

Answer 86

noncardiac

Question 87

Left-sided heart failure refers to failure of the left ventricle, which results in ________________ congestion

Answer 87

pulmonary

Question 88

T/F: ACE inhibitors are recommended for prevention of HF in patients at risk due to vascular disease and diabetes

Answer 88

TRUE

Question 89

T/F: Fluid overload and decreased tissue perfusion result when the heart cannot generate cardiac output (CO) sufficient to meet the body's demands for oxygen and nutrients.

Answer 89

True

Question 90

The most characteristic manifestation of hypocalcemia and hypomagnesemia is:

Answer 90

Tetany

Question 91

A nurse is caring for a client diagnosed with hypovolemic hyponatremia. Which IV solution should the nurse anticipate?

Answer 91

0.9% NS | b/c it is also going to replace sodium

Question 92

A nurse is providing discharge instructions to a client diagnosed with ESRD. The nurse explains that the client is at risk for developing hypernatremia. Which manifestation should the nurse instruct the client to report immediately to a healthcare provider?

Answer 92

Weight gain of 3 lb in 1 day

Question 93

An elderly clients prescribed furosemide 40mg PO for the treatment of CHF. A nurse teaches the client to observe for signs of potassium imbalance while taking this medication. Which signs should the nurse include?

Answer 93

General muscle weakness, constipation, weak, thready pulse

Question 94

After receiving change-of-shift report, which patient should the nurse assess first? The patient with: serum potassium level of 5.2 mEq/L who is complaining of abdominal cramping serum sodium level of 150 mEq/L who has a dry mouth and is asking for a glass of water serum magnesium level of 1.1 mg/dL who has tremors and hyperactive deep tendon reflexes serum phosphorus level of 4.8 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Answer 94

serum magnesium level of 1.1 mg/dL who has tremors and hyperactive deep tendon reflexes -worry about cardiac effects- torsades

Question 95

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking Maalox at home for indigestion. Which action should the nurse take first?

Answer 95

Notify the patient’s health care provider

Question 96

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to Acute Decompensated Heart Failure (ADHF)?

Answer 96

Take medications as prescribed.

Question 97

While working in an outpatient medical clinic, the nurse recognizes a client is experiencing intermittent claudication when the client reports:

Answer 97

“My legs cramp whenever I walk more than a block.”

Question 98

The nurse is managing care for a client with a DVT (deep vein thrombosis) of the right calf. The client receives heparin intravenously (IV). What is the priority outcome for this client?

Answer 98

The client will not experience bleeding.

Question 99

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure?

Answer 99

Hypotension and tachycardia

Question 100

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes , A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C). A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled.

Answer 100

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath

Question 101

Acute pulmonary edema caused by heart failure is usually a result of damage to which area of the heart?

Answer 101

Left ventricle.

Question 102

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside what should the nurse assess first?

Answer 102

Blood pressure Why?- sudden difficulty breathing: need to make sure that BP can take a sudden change in position- could become hypotensive

Question 103

Heart failure patients should have less than ____________ mg of sodium per day.

Answer 103

2,000 mg

Question 104

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

Answer 104

Elevate the head ofthe bed to a high-Fowler's position.

Question 105

The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip. In anticipation of discharge the healthcare provider (HCP) orders warfarin. Which action should the nurse take?

Answer 105

Administer the warfarin along with the heparin drip as ordered.

Question 106

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3–) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Answer 106

Metabolic alkalosis Explanation: A pH over 7.45 with a HCO3– level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3–. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

Question 107

0.45% NaCl is a __________ solution

Answer 107

hypotonic

Question 108

Lactated Ringer solution and normal saline (0.9% NaCl) are ________ solutions

Answer 108

isotonic

Question 109

A 5% NaCl solution is _______?

Answer 109

hypertonic

Question 110

A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider?

Answer 110

Takes high doses of vitamin D b/c- hypercalcemia can affect many organ systems when calcium levels acutely rise; someone taking Vit. D is also increases absorption of calcium leading to their s/s

Question 111

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Answer 111

Serum bicarbonate of 28 mEq/L | b/c metabolic alkalosis evaluation would reveal a pH >7.45 and a serum bicarb concentration ?26 mEq/L

Question 112

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Answer 112

Hypokalemia | b/c it is a potassium wasting diuretic and could drop levels lower than 3.5 mEq/L

Question 113

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Answer 113

Instruct the client to breathe into a paper bag. b/c these findings indicate respiratory alkalosis, so in order to raise the PaCO2 levels (normal range is 38-42mm Hg), it would be best to breathe into bag

Question 114

Which nerve is implicated in the Chvostek’s sign?

Answer 114

Facial | this sign is associated w/ hypocalcemia

Question 115

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Answer 115

Metabolic acidosis | It is characterized by a low pH (which indicated increased H+ concentration) and a low bicarb concentration.

Question 116

This clinical disturbance is characterized by a high pH (decreased H+ concentration) and high plasma bicarbonate concentration

Answer 116

metabolic alkalosis

Question 117

This clinical disturbance is characterized by a pH less than 7.35 and the PaCO@ greater than 42mm Hg and a compensatory increase in the plasma HCO2 occurs

Answer 117

respiratory acidosis

Question 118

This clinical disturbance occurs when the arterial pH is greater than 7.45 and the PaCO2 is less than 38mm hg

Answer 118

respiratory alkalosis

Question 119

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?

Answer 119

dehydration | b/c impaired thirst stimulation, use of diuretics, medications etc.

Question 120

0.9% normal saline is considered a _______ solution

Answer 120

isotonic

Question 121

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Answer 121

Potassium: 5.8 mEq/L | b/c elevated levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias

Question 122

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Answer 122

Osmosis | b/c it is the movement of water

Question 123

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of:

Answer 123

Increased PaCO2. b/c as the body becomes more alkalinized, the respiratory system compensates by decreasing ventilation to conserve CO2 (which converts to carbonic acid and would help to acidify the body) in order to increase the PaCO2

Question 124

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

Answer 124

pH 7.48 | metabolic alkalosis is characterized by high pH and high plasma bicarb concentration.

Question 125

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Answer 125

Insensible fluid loss | geriatric clients are at a high risk for insensible fluid loss through perspiration and vapors in exhaled air

Question 126

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Answer 126

Sodium b/c it plays a major role is controlling water distribution throughout the body b/c it does not easily cross the intracellular wall membrane & b/c it is abundant in body

Question 127

Which is the most common cause of symptomatic hypomagnesemia?

Answer 127

alcoholism | s/s of hypomagnesemia, hyperrelexia, confusion, muscle cramps, seizures, abnormal heart rhythms

Question 128

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Answer 128

acidic | b/c normal urine is 4.5- 8.0

Question 129

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH?

Answer 129

The lungs are not able to blow off carbon dioxide b/c d/t the COPD, the lungs are not able to blow off the carbon dioxide, this leaves a large amount of H+ in the system, making it more acidic. (WK: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system.)

Question 130

To confirm an acid–base imbalance, it is necessary to assess which findings from a client’s arterial blood gas (ABG) results? Select all that apply.

Answer 130

pH PaCO2 HCO3

Question 131

A client with hypervolemia asks the nurse by what mechanism the sodium–potassium pump will move the excess body fluid. What is the nurse's best answer?

Answer 131

active transport | b/c it is maintained by cell membrane for movement of fluid from lower to higher concentration. it uses ATP for energy.

Question 132

The nurse notes that a client has lost 5 lbs. (2.27 kg) of body weight over 5 days. Which additional assessment findings indicate to the nurse that the client is experiencing hypovolemia? Select all that apply.

Answer 132

flat neck veins muscle cramps concentrated urine all signs of fluid volume deficit

Question 133

Which electrolyte is a major cation in body fluid?

Answer 133

Potassium K+ | it affects cardiac muscle functioning

Question 134

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Answer 134

Prepare to assist with ventilation. | b/c respiratory acidosis is associated w/ hypoventilation.

Question 135

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

Answer 135

tingling in the finger is a s/s of hypokalemia

Question 136

signs of hypercalcemia include:

Answer 136

flank pain, polyuria, and hypertension

Question 137

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Answer 137

Arterial blood gas (ABG) analysis is the only test to evaluate gas exchange in the lungs which can provide information about the oxygenation status

Question 138

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?

Answer 138

Discontinue the intravenous lactated Ringer solution. b/c it is contributing to the fluid volume excess and the hyperkalemia

Question 139

Which is the preferred route of administration for potassium?

Answer 139

oral b/c causes the least amount of irritation; should never be given as IV push and if given IV, pt is on a continuous ECG

Question 140

A client who complains of an “acid stomach” has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid–base imbalance?

Answer 140

metabolic alkalosis b/c it causes a decrease in H+ ions when there is an accumulated base bicarbonate

Question 141

At which serum sodium concentration might convulsions or coma occur?

Answer 141

130 mEq/L (130 mmol/L) normal level 135-145; when >135, hyponatremia occurs- mental confusion, muscle weakness, anorexia, restlessness, elevated temp, tachycardia, n/v, personality changes. convulsions/ coma can occur is deficit is severe

Question 142

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Answer 142

Jugular vein distention b/c SIADH causes overproduction of ADH which leads to too much fluid retention.

Question 143

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Answer 143

osmosis b/c it is the movement of water

Question 144

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

Answer 144

280 mOsm/kg Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.

Question 145

With which condition should the nurse expect that a decrease in serum osmolality will occur?

Answer 145

kidney failure b/c it can result in multiple fluid & electrolyte imbalances

Question 146

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Answer 146

cerebral edema

Question 147

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3–), 24 mEq/L. Based on these values, the nurse suspects:

Answer 147

respiratory alkalosis. | pH high = alkalosis; below normal PaCO2- means acid loss d/t hyperventilation meaning respiratory

Question 148

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Answer 148

Chest pain Explanation: Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain.

Question 149

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?

Answer 149

bicarbonate–carbonic acid buffer system

Question 150

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder?

Answer 150

Metabolic acidosis pH low= acidosis, the HCo3 is below normal which reflects an overwhelming accumulation of acids, or excessive loss of base- indicating metabolic acidosis

Question 151

S/s of respiratory alkalosis:

Answer 151

The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs)

Question 152

Oncotic pressure refers to the

Answer 152

osmotic pressure exerted by proteins. Explanation: Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

Question 153

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

Answer 153

0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

Question 154

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

Answer 154

IV b/c class I- no undue fatigue, dyspnea, palpitations or chest pain. Class II, ADLs are slightly limited and III are markedly limited

Question 155

A client has been diagnosed with heart failure. What is the major nursing outcome for the client?

Answer 155

reduce workload of the heart *important part of this Q is nursing outcome- medical management of heart failure means to reduce preload and afterload of the heart

Question 156

The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?

Answer 156

Hold the medication and call the health care provider. hydralazine is an alternative for pts that can't take ACE inhibitors. Nitrates cause venous dilation so this combo of meds would lower the BP even more, which could lead to severe hypotension

Question 157

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Answer 157

echocardiogram- looks at the modeling of the heart | ECG, serum electrolytes, and BUN are done during the initial workup, not as confirmatory tests

Question 158

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?

Answer 158

Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias).

Question 159

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?

Answer 159

gradual unexplained weight d/t fluid retention

Question 160

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

Answer 160

An echocardiogram- b/c it will helps to assess ventricular function and an echocardiogram will help determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, this confirming the dx of HF

Question 161

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Answer 161

pulmonary congestion L ventricle can't pump blood out out of the ventricle into the aorta, blood backs up into the pulmonary system and causes congestion, shortness of breath

Question 162

How does furosemide work for HF?

Answer 162

it is a loop diuretic that inhibit sodium and chloride reabsorption in the ascending loop of Henle. if you are excreting more sodium, water follows it *they are besties* so you excrete more fluid

Question 163

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Answer 163

Class I- | ordinary activity does not cause symptoms

Question 164

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating

Answer 164

orthopnea

Question 165

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

Answer 165

echocardiogram- shows model of the heart and can determine ejection fraction

Question 166

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?

Answer 166

heart rate of 55 beats per minute b/c digoxin slows conduction through the AV node to lower the HR; since it is already slow we would hold and notify the provider

Question 167

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

Answer 167

decompensated heart failure with pulmonary edema. | difference between this and pneumonia is that this has coarse crackles

Question 168

Which is a characteristic of right-sided heart failure?

Answer 168

jugular vein distension | fluid is backing up from the periphery

Question 169

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?

Answer 169

Brain natriuretic peptide (BNP)- high levels of BNP are a sign of high cardiac filling pressure and can aid in the dx of HF

Question 170

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?

Answer 170

Treat pulseless ventricular tachycardia. it is an antiarrhythmic.

Question 171

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Answer 171

Potassium levels b/c if the pt becomes hypokalemic, it will increase levels of digoxin and can lead to toxicity. low K = higher levels of digoxin effects

Question 172

A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus?

Answer 172

Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Explanation: To determine pulsus paradoxus, the nurse should measure blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart.

Question 173

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

Answer 173

The client says his rings have become tight and are difficult to remove.

Question 174

A client with heart failure is taking an angiotensin-converting enzyme inhibitor (ACE-I) and reports a nagging cough. Which replacement medication will the nurse expect to be prescribed for this client?

Answer 174

Losartan Explanation: An adverse effect of ACE inhibitors includes a dry, persistent cough that may not respond to cough suppressants due to the inhibition of the enzyme kininase, which inactivates bradykinin. If the client cannot continue taking an ACE inhibitor because of development of a cough, an angiotensin receptor blocker (ARB) is prescribed, such as losartan. A beta-adrenergic blocker, such as metoprolol, or aldosterone antagonist, such as spironolactone, are not prescribed for the client experiencing the adverse effect of a cough from an ACI inhibitor. Calcium channel blockers, such as diltiazem, are not used to treat heart failure.

Question 175

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?

Answer 175

decrease in renal perfusion Explanation: A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

Question 176

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Answer 176

Atrial fibrillation Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

Question 177

When caring for a patient who has had a pulmonary embolism, the nurse must be alert for the potential complication of right ventricular failure or ______________ shock.

Answer 177

cardiogenic

Question 178

Influenza and ____________ are the most common causes of death from infectious diseases in the United States.

Answer 178

pneumonia

Question 179

T/F: Adequate treatment of upper respiratory tract infection is one of the major factors in the prevention of acute bronchitis.

Answer 179

True

Question 180

Fractures of the first three ribs are rare but can result in a high mortality rate because they are associated with _________________ of the subclavian artery or vein.

Answer 180

laceration

Question 181

T/F: Antibiotics are the initial medical treatment of choice in viral upper respiratory tract infections and pneumonia.

Answer 181

FALSE | antibiotics don't work for viruses

Question 182

Nursing measures to prevent atelectasis include frequent turning, early mobilization, and strategies to ___________________ the lungs and to manage secretions.

Answer 182

expand

Question 183

T/F: Adenocarcinoma is the rarest carcinoma of the lung in both men and women; it occurs peripherally as peripheral masses or nodules and often metastasizes

Answer 183

False

Question 184

The main symptom of pulmonary hypertension is ____________, which occurs at first with exertion and eventually at rest.

Answer 184

dyspnea

Question 185

T/F: | Tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis.

Answer 185

True

Question 186

T/F: The major cause of death in ARDS is nonpulmonary multiple organ dysfunction syndrome, often with sepsis.

Answer 186

True

Question 187

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Answer 187

Chest tube connected to suction | b/c-

Question 188

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

Answer 188

Teach the patient about providing specimens for 3 consecutive days

Question 189

A post-surgical patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

Answer 189

Assist the patient to splint the chest when coughing b/c- promoting airway clearance is most important, most likely in pain d/t surgery pursed lips breathing helps blow off CO2 but won't clear secretions

Question 190

Twenty-four hours after a patient had a tracheostomy, the tube is accidentally dislodged after a coughing episode. Which action should the nurse take first?

Answer 190

Grasp the retention sutures to spread the tracheostomy opening

Question 191

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding?

Answer 191

Localized decreased breath sounds

Question 192

The wife of the client diagnosed with chronic alcoholism tells the nurse, "I have to call his work just about every Monday to let them know he is ill or he will lose his job." Which would be the nurses best response?

Answer 192

"Can you explain to me why you feel the need to call in for him?" b/c she is enabling the addiction

Question 193

The client diagnosed with substance abuse is being discharged from a drug and alcohol rehabilitation facility. The nurse will tell the client which of the following?

Answer 193

"It is important that you attend a 12-step meeting regularly."

Question 194

The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal passages. The nurse also notes dilated pupils and tachycardia. The facility has a "No Drug" policy. Which intervention should the nurse implement?

Answer 194

Notify the client's supervisor about the situation. | not a HIPPA violation b/c it is a policy- go up chain of command

Question 195

The client is withdrawing from a heroin addiction. The nurse will implement all of the following interventions except for which one? Initiate seizure precautions. Place the client on a telemetry monitor. Place the client in a quiet, calm atmosphere. Administer NSAID's for pain.

Answer 195

Initiate seizure precautions. | b/c this is for alcohol most times

Question 196

The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has "started using again". Which action should the nurse implement?

Answer 196

Tell Client A the nurse cannot discuss Client B with him. | HIPAA violation

Question 197

The nurse observes a coworker acting erratically. The clients assigned to this coworker don't seem to get relief when pain medications are administered. Which action should the nurse implement?

Answer 197

Report the nurse's suspicions to the nurse's supervisor or the facility's peer review.

Question 198

The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. Which symptoms would the nurse assess in the client?

Answer 198

Ataxia and memory disorders. | coordination and memory disorder s

Question 199

The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering?

Answer 199

Thiamine and lorazepam.

Question 200

The friend of an 18-year-old male client brings the client to the ED. The client is unconscious, and his breathing is slow and shallow. Which action should the nurse implement first?

Answer 200

Apply oxygen at 100% via nasal cannula. | ABC questions b/c breathing is slow & shallow

Question 201

The nurse caring for a client abusing amphetamines writes a problem of "cardiovascular compromise." Which nursing intervention should be implemented?

Answer 201

Monitor the telemetry and vital signs every two hours.

Question 202

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Answer 202

Cough or change in chronic cough

Question 203

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Answer 203

Tension pneumothorax Explanation: Clamping can result in a tension pneumothorax

Question 204

Which action should the nurse take first in caring for a client during an acute asthma attack?

Answer 204

Administer bronchodilator as ordered. Explanation: Administering bronchodilator will dilate the airway and allow oxygen to reach the lungs. Good example of a do 1 thing and walk away question.

Question 205

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

Answer 205

empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

Question 206

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Answer 206

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Explanation: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

Question 207

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Answer 207

Developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

Question 208

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Answer 208

Blood-tinged sputum Explanation: The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.

Question 209

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Answer 209

Significant Explanation: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

Question 210

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Answer 210

Tense and relax muscles in the lower extremities. Explanation: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients.

Question 211

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Answer 211

Vitamin B6 Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

Question 212

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

Answer 212

See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

Question 213

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Answer 213

Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

Question 214

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

Answer 214

continue to take antibiotics for the entire 10 days. Explanation: The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

Question 215

On auscultation, which finding suggests a right pneumothorax?

Answer 215

Absence of breath sounds in the right thorax Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

Question 216

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

Answer 216

asbestos. Explanation: Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos.

Question 217

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?

Answer 217

pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

Question 218

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Answer 218

Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

Question 219

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Answer 219

Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

Question 220

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

Answer 220

Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

Question 221

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

Answer 221

"Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

Question 222

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Answer 222

Progressive loss of lung function associated with chronic disease Explanation: In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease.

Question 223

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Answer 223

Fibrotic changes in lungs Explanation: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

Question 224

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

Answer 224

Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia.

Question 225

The nurse is assessing a client’s potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Answer 225

Localized calf tenderness Explanation: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client’s urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

Question 226

Which intervention does a nurse implement for clients with empyema?

Answer 226

Encourage breathing exercises Explanation: Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.

Question 227

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient’s shirt. What does the nurse know that this finding indicates?

Answer 227

Flail chest Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient’s ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

Question 228

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress?

Answer 228

Normal lung function Explanation: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.

Question 229

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

Answer 229

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

Question 230

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis?

Answer 230

Pain in the calf Explanation: When assessing the client's potential for pulmonary emboli, the client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain during this maneuver, he or she may have a deep vein thrombosis.

Question 231

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Answer 231

Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

Question 232

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Answer 232

Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

Question 233

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

Answer 233

Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

Question 234

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Answer 234

Encouraging increased fluid intake Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

Question 235

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?

Answer 235

Impaired Gas Exchange Explanation: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.

Question 236

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn’s disease. What results would the nurse determine is not significant for holding the medication?

Answer 236

0 to 4 mm Explanation: The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

Question 237

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

Answer 237

6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

Question 238

The nurse needs to educate the client with pneumonia about the medical regimen, signs and symptoms to report, measures to prevent pneumonia, and supportive care.

Answer 238

Because the client is 65 years old and has previously been vaccinated with PCV13, the client should receive the PPSV23 vaccination. The client is also correct that breathing humidified air helps to liquefy secretions and relieve tracheobronchial irritation. Additionally, the client understands that a worsening cough can signal a lack of response to the antibiotics and a deterioration in the client's condition. The client with pneumonia should also obtain adequate rest and avoid overexertion. The nurse needs to reinforce to the client that, to successfully treat pneumonia, antibiotics need to be taken for the fully prescribed course and should not be stopped when symptoms subside. The nurse should also reinforce that the client should drink 2 to 3 liters of fluid each day because hydration thins and loosens pulmonary secretions. Additionally, a persistent and recurrent fever after starting antibiotics is not an expected therapeutic response to antibiotics and requires medical attention. Performing deep-breathing exercises once a day is not sufficient to inflate alveoli and prevent atelectasis. These exercises should be performed at least every 2 hours.

Question 239

The nurse is auscultating the patient’s lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Answer 239

Crackles in the lung bases Explanation: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

Question 240

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Answer 240

Dyspnea Explanation: Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

Question 241

The most diagnostic clinical symptom of pleurisy is:

Answer 241

Stabbing pain during respiratory movements. Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

Question 242

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

Answer 242

Chest pain and dyspnea Explanation: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

Question 243

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?

Answer 243

A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.

Question 244

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

Answer 244

A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

Question 245

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

Answer 245

pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

Question 246

Asthma causes airway____________________, mucosal edema, and mucus production

Answer 246

hyperresponsiveness

Question 247

T/F: Asthma is considered a distinct, separate disorder from COPD and is classified as an abnormal airway condition characterized primarily by reversible inflammation.

Answer 247

True

Question 248

COPD is generally a progressive disease characterized by three primary symptoms: chronic cough, sputum production, and ________________.

Answer 248

dyspnea

Question 249

The most potent and effective anti-inflammatory medications currently available to treat asthma are _________________.

Answer 249

corticosteroids

Question 250

T/F: Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection.

Answer 250

True

Question 251

The cornerstone pharmacologic therapy of bronchiectasis management is the use of____

Answer 251

antibiotics

Question 252

Administering oxygen to patients with COPD will result in cardiopulmonary arrest by suppressing the drive to breathe.

Answer 252

False- can receive small amounts of o2

Question 253

The overall goals of ________________ care are to manage symptoms and improve the quality of life for patients and families with advanced COPD.

Answer 253

palliative

Question 254

T/F: The pathophysiology of emphysema involves destruction of the walls of the alveoli leading to impaired oxygen diffusion.

Answer 254

True

Question 255

T/F: Smoking cessation is the single most cost-effective intervention to reduce the risk of developing COPD and to stop its progression

Answer 255

True

Question 256

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?

Answer 256

Encourage the patient to sit up at the bedside in a chair and lean forward

Question 257

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

Answer 257

Peripheral edema

Question 258

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)?

Answer 258

“Use your bronchodilator before you start to exercise.”

Question 259

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A patient: with loud expiratory wheezes with a respiratory rate of 36 breaths/min who has a cough productive of thick, green mucus with 4+ pitting, peripheral edema

Answer 259

with a respiratory rate of 36 breaths/min

Question 260

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?

Answer 260

Walk 15 to 20 minutes a day at least 3 times/week

Question 261

The public health nurse is presenting a health-promotion class to a group at a local community center. Which intervention most directly addresses the leading cause of cancer deaths in North America?

Answer 261

Smoking cessation

Question 262

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?

Answer 262

The client diagnosed with chronic heart failure being discharged this morning. The client with frequent incontinent liquid bowel movements and vomiting. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. The client reporting chest pain on inspiration and a nonproductive cough.

Question 263

The client is receiving low molecular weight heparin subcutaneously to prevent a DVT following hip replacement surgery. The client reports to the nurse that there are small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement?

Answer 263

Explain this is the result of the medication.

Question 264

The client is one day postoperative AAA repair. Which information from the UAP would require immediate intervention from the RN?

Answer 264

The client's urinary output is 90 mL in 6 hours.

Question 265

The client diagnosed with CAD is prescribed transdermal nitroglycerin. Which behavior indicates the client understands the discharge teaching concerning this medication?

Answer 265

The client removes the old patch and waits the appropriate amount of time before replacing the new.

Question 266

Which medication should the nurse expect the HCP to order for a client with peripheral arterial disease?

Answer 266

An antiplatelet medication.

Question 267

The RN and UAP are bathing a bedfast client. Which action by the UAP warrants immediate intervention?

Answer 267

The UAP begins to massage and rub lotion into the client's calf.

Question 268

The client diagnosed with peripheral vascular disease is overweight, has smoked two packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions?

Answer 268

Smoking cigarettes.

Question 269

The charge nurse is making assignments for clients on the cardiac unit. Which client should the charge nurse assign to the new graduate nurse?

Answer 269

The 75-year-old client scheduled for a cardiac catheterization.

Question 270

The nurse is administering morning medications. Which medication should be administered first?

Answer 270

The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL demanding breakfast.

Question 271

The client diagnosed with an ST elevation MI (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which intervention should the nurse implement first?

Answer 271

Notify the Healthcare Provider (HCP).

Question 272

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client? Elderly clients:

Answer 272

have less physiologic reserve than younger clients

Question 273

Which statement describes emphysema?

Answer 273

A disease of the airways characterized by destruction of the walls of overdistended alveoli Explanation: Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

Question 274

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse’s concern? Select all that apply.

Answer 274

Compromised gas exchange Decreased airflow Wheezes

Question 275

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid–base imbalances?

Answer 275

Respiratory acidosis Explanation: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid–base imbalances would not correlate with COPD.

Question 276

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

Answer 276

albuterol (Proventil). Explanation: The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

Question 277

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client?

Answer 277

Increase walking distance around a city block without shortness of breath. Explanation: If the client has mild COPD, goals are to increase exercise and prevent further loss of pulmonary function. The client who increases his walking distance without shortness of breath meets these criteria. If the client has severe COPD, goals are then to preserve current pulmonary function and relieve symptoms as much as possible. Examples of these goals are the other options, in which the activity level is at current and symptoms are relieved to tolerable or close to tolerable.

Question 278

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

Answer 278

"Weigh yourself daily and report a gain of 2 lb in 1 day." Explanation: The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy. The client shouldn't smoke at all.

Question 279

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure?

Answer 279

Respiratory acidosis Explanation: In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

Question 280

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?

Answer 280

Sputum and a productive cough Explanation: Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years.

Question 281

A client has intermittent asthma attacks. Which of the following therapies does the nurse teach the client to use at home when experiencing an asthma attack?

Answer 281

Inhaled albuterol (Ventolin)

Question 282

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

Answer 282

Respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

Question 283

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Answer 283

Respiratory rate of 22 breaths/minute Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Question 284

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?

Answer 284

Atelectasis Explanation: In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Question 285

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

Answer 285

Decreased oxygen requirements Explanation: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

Question 286

The classification of Stage III of COPD is defined as

Answer 286

severe COPD. Explanation: Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

Question 287

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one type of disorder within its classification. Which of the following is part of that disorder?

Answer 287

Emphysema COPD may include diseases that cause airflow obstruction (e.g., emphysema, chronic bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of COPD are now classified as chronic pulmonary disorders. Asthma is now considered a distinct, separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation.

Question 288

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Answer 288

Anxiety Explanation: In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis

Question 289

Which of the following is accurate regarding status asthmaticus?

Answer 289

A severe asthma episode that is refractory to initial therapy Explanation: Status asthmaticus is a severe asthma episode that is refractory to initial therapy. It is a medical emergency. Patients report rapid progressive chest tightness, wheezing, dry cough, and shortness of breath. It may occur with little or no warning.